1. EEK FITNESS, INC.
P.O. BOX 185 SAN JACINTO CA, 92581
Aikido Program-Fall 2013
August 31st
thru November 23rd
(No class on September 7th
)
PLEASE PRINT
NAME: __
STREET ADDRESS: ___________________________________________________________
CITY: ZIP CODE:____________________
DATE OF BIRTH: AGE AT REGISTRATION:______
HEIGHT: WEIGHT:__________ SEX:______
DISABILITY ________
______________________________________________________________________________
PARENT / LEGAL GUARDIAN NAME (S): _________________________________________
HOME PHONE #: WORK PHONE # :______________________
CELL PHONE#: ___________________
E -MAIL ADDRESS ___________

2. AS THE PARENT OR LEGAL GUARDIAN OF THE CHILD NAMED ABOVE I HEREBY
GIVE MY FULL CONSENT AND APPROVAL FOR MY CHILD TO PARTICIPATE in EEK’s
AIKIDO CLASS. I HEREBY CERTIFY THAT MY CHILD IS HEALTHY AND HAS NO
PHYSICAL OR MENTAL DISABILITIES THAT WOULD RESTRICT FULL PARTICIPATION
IN THESE ACTIVITIES, EXCEPT AS LISTED PREVIOUSLY. IN ADDITION, I HEREBY
WAIVE AND RELEASE AND HOLD HARMLESS EEK FITNESS INC, ITS OFFICERS,
DIRECTORS, INSTRUCTORS, INDEPENDENT CONTRACTORS, VOLUNTEERS,
SPONSORS, SUPERVISORS, AND REPRESENTATIVES FOR ANY INJURY THAT MAY BE
SUFFERED BY MY CHILD IN THE NORMAL COURSE OF PARTICIPATION IN THE
DESIGNATED PROGRAM AND THE ACTIVITIES INCIDENTIAL THERETO, WHETHER
THE RESULT OF NEGLIGENCE OR ANY OTHER CAUSE.
PARENT’S SIGNATURE :____________________________________________________
DATE: _____________
TO CONTACT US: (951) 303-7892 Margaret
margaretnambiar@gmail.com
eekandfriends.com
EEK FITNESS, INC.
A PUBLIC NONPROFIT ORGANIZATION FOR THE BENEFIT OF
INDIVIDUALS WITH DISABILITIES AND THEIR FAMILIES.
.
START DATE: August 31st, 2013
(No class on September 7th
)
COST: $20 /month or $50 for entire 12 wk program
LOCATION:
Hemet High School
Multi-Purpose Room