RGSTKD Taerobixx™ Registration Form

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Taerobixx™ Registration

Complete the form, print it, sign it, and bring it to the school. You may pay by credit card or check. If you opt for credit card, click on Submit after the form is completed.

* indicates required information

Personal Information

*Student First Name:	*Student Last Name:	DOB (mm/dd/yyyy)
Parent First Name:	Parent Last Name:	*Address:
*City:	*Zip:	*State:
*Home Phone	Work Phone
*Email Address:

Please make checks payable to: Robert Giorgio
Applications with check attached must be returned before the posted deadline.
Students may not start classes until they are registered. If there are any questions,
please contact Mr. Giorgio at (508) 443-2277.

Session Information

Sessions Plan:
Participation in TAEROBIXX™ requires the use of approved equipment. TAEROBIXX™ equipment can be obtained through the school; any equipment purchased outside the school must be approved by Mr. Giorgio.
Gloves: $30.00	Hand Wraps: $10.00	Jump Rope: $13.00	T-Shirt: $8.00
Session Fee:	Total:

Emergency Contact Information

Emergency Contact Name:			Emergency Contact Phone:
Doctor's Name:			Doctor's Phone:
Dentist's Name:			Doctor's Phone:
Hospital:			Hospital Phone:

Pre-existing Conditions

Pre-existing physical or mental conditions that may impair your participation in Taekown-Do classes:

Waiver of Liability

RELEASE AND WAIVER OF LIABILITY

I realize that participation in TAEROBIXX™ involves some risk of personal injury; therefore, as the parent or legal guardian of , I hereby grant permission for him/her to participate in TAEROBIXX™ and related events at Robert Giorgio's School of Taekwon-Do, Inc.

I , hereby release and forever discharge Robert Giorgios School of Taekwon-Do Inc., it's owners, officers, employees, and fellow students from any and all damage to or loss of property, physical or emotional injury, or suffering resulting from s participation in TAEROBIXX™.

Credit Card Purchase

Card Number:		Card Type:	Expiration Date: Month
		Year(Range:00~20)
	Submit

Signature

Signature of Applicant/Legal Guardian Date:

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