Release Form - Piscataway Dojo (Page 4 of 4) in pdf

PISCATAWAY RECREATION DEPARTMENT

455 HOES LANE

732-562-2382

CUONG NHU MARTIAL ARTS

REGISTRATION FORM

FREE FOR PISCATAWAY RESIDENTS FROM 6 TO 15 YEARS OLD & ADULTS

Limited Availability

ATTIRE: SWEAT PANTS, T-SHIRTS, LOOSE CLOTHING (NO JEWELRY)

Print out and complete this form and submit it to the Martial Arts Instructor.

PARTICIPANT’S NAME ______________________________________________ AGE_________

ADDRESS ________________________________________________________________________

PHONE # (HOME) _______________________________ (CELL) ____________________________

EMAIL ADDRESS _________________________________________________________________

HAVE YOU HAD ANY PREVIOUS MARTIAL ARTS INSTRUCTION? YES

IF YES, PLEASE DESCRIBE: __________________________________________________

_______________________________________________________________________________

Medical Alert – Yes

Do you require special accommodations? – Yes

Do you have special needs? – Yes

If you checked “Yes” to any of the above, please elaborate on back of form.

In Case of Emergency Contact:

Name: ____________________________________ Phone: ______________________________

Relation: ___________________________

____________________________________________

SIGNATURE (if a minor, parent’s signature)

Participants in the Piscataway Recreation sponsored events do so at their own risk and accept full responsibility for all their actions and injuries

incurred by their participation. Prior to submitting a claim to the Township, injured parties must first use their own medical/accident insurance as

their primary coverage. The insurance offered by Piscataway Township is supplemental and secondary only. If a claim qualifies for consideration, the

Township insurance is limited to a maximum payout of no more than $5, 000.00 per accident.

It is now mandatory in New Jersey for all school aged youth that wear corrective eyewear while participating in

recreation programs and activities to wear “Protective Eyewear” that meets (ASTM) American Society for Testing and

Materials standards for frames, and (ASNI) American National Standards Institute standards for lenses.

Complete and Return this form with your registration.

Release Form - Piscataway Dojo Page 4