Xtreme Martial Arts Academy

Passion Respect
Discipline

Joining Application

Family Name: __________________ First Names:_____________________________

Address:______________________________________________________________

_____________________________________________________________________

Telephone No. ( 0 ) H: _____________ W: _____________ Fax: _____________

Mobile: ( 02 )_____________ Email Address:_________________________________

Date of Birth: _________________________ Gender: M / F Age: ____ yrs

Occupation:___________________________________________________________

Any medical condition your instructor should know of?

_____________________________________________________________________
_____________________________________________________________________

Do you have any other family members training? yes / no

Who?________________________

Any previous martial arts experience? yes / no Details

_____________________________________________________________________
_____________________________________________________________________

Class/es joining: Taekwon-Do Kickboxing

DECLARATION

I hereby agree to abide by the following conditions:

20A Subway Road

Pukekohe, 2120 Phone: +64 9 2390607 www.xmaacademy.co.nz

New Zealand Mob: +64 27 4488038 email: luke@xmaacademy.co.nz

 Xtreme Martial Arts Academy
Passion Respect
Discipline

1. The instructor has the right to withhold tuition from me if I disturb the class in any way.

2. I hold myself responsible for any injury that I may sustain in the course of my training.

3. I agree not to misuse the knowledge gained through the classes.

4. There shall be no refund of my membership or training fees paid in advance.

PRIVACY ACT
I give my permission for the Xtreme Martial Arts Academy Ltd. to collect, store and use any
information provided by me, as well as any information collected about my progress or activities
in the classes or activities I participate through the Xtreme Martial Arts Academy, for its own
purposes and business only. I understand that this information will not be disclosed to any other
organisations without my prior consent. I recognise the right to view this information and make
corrections where appropriate.

I have read and accept the above conditions.

_________________ ________________________

(Applicant’s signature) (Parent's/Guardian's signature) if applicant is under 18.

Date: ____________

20A Subway Road

Pukekohe, 2120 Phone: +64 9 2390607 www.xmaacademy.co.nz

New Zealand Mob: +64 27 4488038 email: luke@xmaacademy.co.nz