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STUDENT NAME
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AGE
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ADDRESS
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CITY, ST
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ZIP CODE
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PHONE NUMBER
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ARE YOU
WILLING TO
RECEIVE TEXT
MESSAGES?
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E-MAIL ADDRESS
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PERSON TO BE
CONTACTED IN
CASE OF
EMERGENCY?
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RELEASE OF RISK AND PHOTOGRAPHY PERMISSION FOR MINORS
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I, the undersigned, parent of the student above, hereby acknowledge that I am aware of and fully
understand nature of the physical activity in which I have requested that my child be allowed to participate
in. I further am aware and understand that with this, as well as other physical activities, there is a risk of
injury and danger of death involved. I knowingly, deliberately, and voluntarily choose to expose my child
thereto and I assume all risks therein. I solemnly make this Covenant, contract, and agreement that, IF my
child experiences an injury (or in the extreme circumstance of death) while participating in a class held by
B&B Tae Kwon Do, I hereby release, or will release (without the tender of payment of any other or
further consideration whatsoever) B&B Tae Kwon Do and all instructors/staff/personnel (an any/all
associations and affiliates thereof) from any and all liabilities. I thereby assume full and sole responsibility
for my child/student and his/her actions. I understand that my child will be properly instructed in techniques
of a physical nature that will require various degrees of agility, flexibility, stamina, endurance, balance,
power, and concentration and will stress to my childe/student that importance of focus, discipline, respect
and most importantly the safety of themselves as well as others. I acknowledge that I have the right to
refrain my child from performing or participating in any activity associated with this and any other classes
by B&B Tae Kwon Do that I deem unsafe and assume all responsibility for my childs's/student's safety.
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I, the undersigned, hereby grant permission for B&B Tae Kwon Do staff or other individuals represented
or appointed by the B&B Tae Kwon Do staff, to take photographs or videos solely for of historical and
promotional purpose. This footage is not to be used otherwise without my permission.
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I, the undersigned, hereby acknowledge that I am aware of the above agreement and that no
misrepresentation of the agreement has been made and as the Parent of the applicant, or as the
applicant/student myself, I hereby consent and agree.
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PARENT/LEGAL
GUARDIAN
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DATE
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