Samjae Tae Kwon Do
Club Registration, Medical and Waiver
Name: ____________________________
DOB (D/M/Y): __________________
Address: _______________________________________
Phone#: __________________
Email: _______________________________________
Emergency Contact: Name: ________________________ Relation: ___________
Contact #: _________________
Do you have any health conditions (ie. medical conditions, allergies, on medications, injuries (particularly concussions),
etc.) that would potentially cause you difficulty when taking part in a high impact sport such as Taekwondo?
NO
YES - ___________________________________________________________________
*If you answered Yes please explain above or on an attached sheet. Physician letter may be required.
Where did you hear about Samjae Taekwondo?
Web Search []
Flyer []
Word of Mouth []
Facebook []
Other - ____________
By applying to membership at the Samjae Tae Kwon Do School, herein afterwards called the Club, I fully understand and
agree to the following:
That my presence and activities are completely at my own risk and I do hereby indemnify, release and forever discharge the Samjae
Tae Kwon Do School or any branch club, its’ owners, instructors, directors, members, agents or any other person connected with the
said Club against all liability and responsibility, and from all claims for personal injury and any loss of personal property sustained by me
or injuries or damage to person or property of others caused by me while engaging in Taekwondo or in activities at or while in or near
the premises or place of activity of the Club ; AND
I am also fully aware that in participating in this activity, there are some inherent risks attached to it that may cause injury.
Without listing the generality of the foregoing, I, as well as my next of kin, heirs or assigns, further releases the Club from any recourse,
which I may now have, or hereafter have resulting from any injuries sustained while participating in the art and sport of Taekwondo
both on and off the premises of Samjae Tae Kwon Do; AND
I represent to Samjae Tae Kwon Do that I have taken all reasonable steps to determine, and hereby warrant, that I OR my
child is in good health and physically capable of participating in the programs and courses of instruction offered by Samjae Tae Kwon
Do. I acknowledge that Samjae Tae Kwon Do shall make no, and have no responsibility to, make any independent evaluation of my
physical health or fitness. I understand and agree that all participation in any such fitness program or use of Samjae Tae Kwon Do's
facilities or equipment on or off the premises of Samjae Tae Kwon Do shall be at my own risk; AND
That I will abide by the rules and regulations of the club and will conduct myself so that I will not disgrace the honor of the
membership AND that in the exchange for membership and lessons received or yet to be received, I will not teach any of the aspects of
Taekwondo, anywhere without the written consent of the Club chief instructor, Mr. Ian Crocker. This clause will be in effect for a period
of three years after cessation of my membership, which must be documented by registered mail sent to Club chief instructor ; AND
That I will agree to pay my membership fees in full and in accordance with the regulations set down concerning such fees and
that the fees will cover the term for that period only, and that no credit or refund shall be made should I not attend classes for whatever
reason, unless special arrangements have been made with Club administration; AND
That any photographs taken of me in connection of the Club may be used for publication or promotion without compensation at
any time; AND
I have read and understood this document and I am aware that by signing this agreement that I am waiving certain
legal rights which I or my heirs, next of kin, executors or assigns may have against Samjae Taekwondo. I also certify that the
above information provided is accurate and recognizing that by providing any false information will result in immediate
termination of membership from Samjae Tae Kwon Do without recourse or refund of membership fees.
_________________________________
SIGNATURE (OR PARENT’S IF UNDER 18)
____________________
DATE
_____________________________
INSTRUCTOR
Samjae Taekwondo adheres to Federal Privacy legislation concerning the protection of personal information. With the exception of
medical emergencies, no information will be disclosed to a third party without the consent of the applicant or his/her parent or legal
guardian.
Newfoundland and Labrador
Amateur Taekwondo Union Inc.
Membership Registration
Name: ____________________
Address: __________________ Date of Birth:_______________
Newfoundland and Labrador
Amateur Taekwondo Union
Inc
155 Torbay Rd
PO Box 21116
ST. JOHN'S, NL
A1A 2H0
Postal Code: ___________ Telephone: ______________ E-mail:__________________________
Dojang Name: ______________________________ Head Instructor: _____________________
Experience (Yrs.): ___
Rank Achieved ___________
(Black Belts: complete below)
Kukkiwon #: ____________________Date that Current Rank was issued: __________________
Please Select Membership Category
0 Colour Belt Member: Sept-Aug: $40.00 / Jan-Aug: $25.00 / June-Aug: $10.00
0 Black Belt / Poom member: Sept-Aug: $40.00 / Jan-Aug: $25.00 / June-Aug: $10.00
0 Master Member (Free) (please provide copy of Kukkiwon Certificate 5th Dan or higher)
0 Life Member (Free)
Do you have a criminal record?  Yes  No
If YES please explain on a separate piece of paper attached to this application.
Do you have a medical condition that would interfere with your participation in Taekwondo?  Yes  No
If YES please explain:
____________________________________________________________________________
I hereby apply for membership to Newfoundland and Labrador Amateur Taekwondo Union (NLATU)) and
I fully understand and agree to the following:
That my presence and activities are completely at my own risk, and I do hereby indemnify, release, and forever discharge the
NLATU and its directors, members, agents and any other person or persons connected with the NLATU, against and from all
liability, and responsibility, and from all claims for personal injuries or any loss of personal property sustained by me or injuries
or damage to persons or property of others caused by me while engaging in Taekwondo or in activities of the said, or while in or near
the premises or places of activity of the NLATU, AND;
That I will honour the NLATU Code of Conduct and conduct myself with honor and integrity, treating all persons with respect, such
that I will not disgrace the honor of this membership, AND;
That any pictures or videos taken of me in connection with the NLATU can be used for publication or promotion without
compensation at any time, AND;
That I will pay membership fees when due, and in accordance with the regulations set down concerning such fees, and that the
fees will cover the term for that period only, and that no credit or refund shall be made unless special arrangements have been
made with the NLATU. Payments may be made by cheque or money order to the NLATU.
I n acc or danc e w ith Fe de ral P ri vac y L egis la tion, the in fo rma tio n co llect ed h er ein is for administrative purposes
of the NLATU only and will not be disclosed to any other parties without the expressed written consent of the applicant and/or
his/her legal guardian.
Sign: ___________________ __
Parent / Guardian (if under 18): ______________________
Date: ___________________ __
Dojang Head Instructor: ____________________________