Application for Martial Arts / Recreational Classes
Information received is confidential and is being gathered for the purposes of serving you/your child while in the care of Japanese
Canadian Cultural Centre. Any medical information collected here serves to authorize the JCCC and its staff and volunteers, toobtain medical assistance in emergencies.

Program:Name:Last Name
Date of Application:

Given Name/

MMMale  Female /
DDYY
Address:
Street, Apt # (if applicable)

City

Postal Code

Telephone:
HomeCell

Email Address:

Date of Birth:@/MM/DDYY

JCCC Membership no.

Expiry Date:
MMPrevious Experience (please circle one):YES

For martial arts, if yes, name of club:_//DDYYNO
Colour of Belt (if applicable)

Medical History
I acknowledge that by participating in this program, I will be involved in rigorous physical and mental training and contact, andtherefore it is important to disclose to the JCCC any health impediment which would impair my ability to participate in any way.
Are there any physical conditions that JCCC staff should be aware of? (Please circle)
 Heart Ailment

 Epilepsy

 Asthma Bone Disease Hernia

 Injuries

 Allergies/Anaphylaxis

Please specify condition:
If you require an epipen, or an inhaler, please bring it with you into the dojo/class.
Are there any emotional, mental, behavioural concerns or limitations that staff should be aware of?  Yes

 NoIf yes, please explain:
In case of an emergency, contact
Name

Contact Number

Relationship

SEE REVERSE
Updated: September 2019

Please read carefully

InitialI authorize JCCC personnel to sign consent for medical treatment and to authorize any physician or hospitalto provide medical assessment, treatment or procedures for the participant named above, if contact
person/parent or guardian cannot be reached in the case of an emergency.
I agree, that any pictures taken of myself or my child(ren) during the program by the JCCC can be used inany promotion or advertisement by the JCCC. (*If you have any concerns, please speak with your instructor.)
I have read and understood and accept the conditions laid out in the JCCC Martial Arts Policy.
I have read and understood and accept the conditions laid out in the JCCC Code of Conduct.
I have read and understood and accept the JCCC pick up and drop off guidelines.

Release of Liability
I hereby make application to join the JCCC program checked above, and upon acceptance of my application, I agree to abide by
the rules and regulations set by the JCCC in connection with the program. In consideration of the JCCC accepting my application
to join the program, I hereby release the Japanese Canadian Cultural Centre, its directors, officers, employees, instructors,
members, volunteers and invitees and licensees from any and all claims, demands, actions, causes of actions, or any otherliability or obligation whatsoever arising out of or in connection with my membership or participation in the Martial Arts program ofthe JCCC, which relating to personal injury or damage to or loss of property or otherwise, whether going to or away from or at orin the premises of the JCCC or elsewhere, and whether in contact or in tort.

Signature of Applicant

Date

Signature of Parent/Guardian (for applicants 18 years and under)

Date

SEE REVERSE
Updated: September 2019