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_______________________________________________ ____/____/____
Name of Participant; last name first		           date

____/____/____     _________       M  or F       _________ 
Date of birth	   Age today    (circle one)   grade in school

_______________________________________________________     ___________________________________
name of adult(s) responsible for participant			 relationship to participant

____________________________________________________________________________________________
billing address

_____________________________  _____________________________  ________________________________
daytime phone                                  evening phone                                  cel or other emergency phone

____________________________________________________________________________________________
email address                    (highly recommended for GKA news updates, but our list is never sold, rented or lent to anyone!)

___________________________________________  _________________________  ______________________
Emergency contact (other than adult/s above)         best phone during class          alt. phone

____  I have received copies of the Equipment Requirements and Recommendations and the Student Expectations Sheet, and I understand that my child will be taught and held responsible for knowing this information in order to participate and advance at GKA.

____  I have read, understood, and signed a copy of the Release and Waiver of Liability and Indemnity Agreement for Green Knight Academy.

____  I understand that GKA bills on a monthly basis for the upcoming month, and that no refunds are given for non-use of classes and/or facilities.

____  I understand that while GKA maintains a certain amount of loaner equipment for use by students, it is best my my child to own his or her own equipment, as students who use school equipment may, of course, have to take turns.

____  I understand that while students are encouraged to practice what they learn by themselves outside of class, it is strictly forbidden for students to engage in any form of combat or combat practice with any other person other than at the GKA campus, or at a GKA-sanctioned event.  

____  I understand that, similar to gymnastics/tumbling and other martial arts, GKA's martial art cannot be taught without my child coming into physical contact with the staff and other students.  This contact may involve pushing and shoving, as well having my child's body position or stance physically adjusted or moved in order to increase safety, minimize or eliminate injury, or improve technique.

____   I understand that while every reasonable effort will be made to accomodate my child's participation, GKA is a private entity and reserves the right to refuse membership to anyone, and that membership can be cancelled at any time, for any reason.  No participant will be refused membership based on his or her (or his or her parent(s) or guardian's) race, ethnicity, religion, gender or sexual orientation.




Is there anything else we should know, or that you would like us to know, about your student (medical conditions, allergies, special requirements or disabilities, etc.)?  














How did you hear about Green Knight Academy?
 billboard         other signage         word-of-mouth         phone book         school visit         saw flier
 other _____________________________________________________________________________________






____________________________________________________________________________________________
I affirm that my answers above are true to the best of my knowledge (sign and date).