Fall 2011 Registration Form

KENPO KARATE with Mr. Salinas Presented through Zion Lutheran Church and school

You can enroll any time. Bring this completed form to first class.

� TUESDAYS 4PM TO 5 PM

� FRIDAYS 4:00 PM TO 5:00 PM

Zion Church and School ~ 1244East Cypress Street ~ Anaheim, CA 92805-3363 Location: Art Room

Participant’s Name:_______________________________________________________________________

Birth Date: ____________ Age:_______Parent’s Name(s):________________________________________

Address:________________________________________________________________________________

________________________________________________________________________________________

Home Phone:________________________Cell or Work Phone:___________________________________

E-Mail Address:__________________________________________________________________________

Alternate Local Emergency Contact: (Name/Phone)_____________________________________________

Payment Enclosed: Make Checks Payable to Jesse Salinas

� $45 per month for one class per week)

� $65 (per month for two classes per week or second participant)

� $25 Uniform Fee (If you do not have one)

MEDICAL CARE AUTHORIZATION

Pursuant to California Family Code §6910, I, , a parent/guardian having legal custody of __________ , a minor child, hereby authorize ZION LUTHERAN CHURCH AND SCHOOL, an adult person into whose care such minor child has been entrusted, to consent to any X-ray examination (or similar examination such as by CAT scan), anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to the minor under the general or special supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical Practice Act or to consent to an X-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to the minor by a dentist licensed under the provisions of the Dental Practice Act. I agree to pay any and all costs for the foregoing. My medical insurance provider is _______ and my insurance certificate number and/or group number is ______________ This authorization shall remain effective until December 30, 2011. Doctor’s name Phone

NOTIFICATION OF PUBLISHING OR SHOWING MINOR CHILD’S STILL OR MOVING IMAGE

I, the parent/guardian of , understand that from time to time pictures are taken during the activities at ZION Lutheran CHURCH AND SCHOOL ANAHIEM , CA, or under its direction, then presented in various church sponsored media. These include, but are not limited to, pictures, video productions, newsletters, television programs, web casts, brochures, handbooks, programs and Internet web pages. This section serves as notification to you that any meetings, events and activities (including worship) are considered public and may be video taped and/or photographed and used in the above listed manner.

Signed Date _____________________

CONSENT, INDEMNIFICATION AND RELEASE AGREEMENT

IN CONSIDERATION of my or my minor child’s participation in Jesse Salinas Kenpo Karate at ZION Church and School and use of any of the premises and facilities any equipment supplied to me or used by me in connection therewith (collectively, “Participation”), to the fullest extent permitted by applicable laws I DO HEREBY agree as follows: 1. I ACKNOWLEDGE THAT THERE MAY BE A RISK OF SERIOUS INJURY (KNOWN OR UNKNOWN) TO ME IN CONNECTION WITH MY OR MY CHILD’S PARTICIPATION AND I ASSUME FULL RESPONSIBILITY FOR, AND ALL RISK OF, any bodily injury, death or property damage that I may suffer for any reason due to my Participation. 2. I RELEASE, COVENANT NOT TO SUE AND AGREE TO INDEMNIFY AND HOLD HARMLESS Jesse Salinas and ZION Lutheran Church and School of and from any and all claims, causes of action, damages, liabilities or expenses (collectively, "Claims"), known or unknown, existing now or in the future, that I may now or hereafter have against the Releasees, arising in any way out of my Participation. Name of Participant: _________________________________________________________________________________ Signature of Participant or Parent if Participant is a minor_____________________________________ _ Date:_______________________

ZION PRESENTS

KENPO KARATE with Mr. Salinas

Fall 2011 ~ Come have fun and learn!

� Students learn respect, discipline and control while mastering karate Techniques and forms.

� Great for fitness! Great for self defense! Great for sport too! Come try it!

Open to

Kindergarteners to

4th grade Parents and family members are encouraged to participate too!

About the Instructor:

Zion Kenpo Karate classes are taught by Mr. Salinas, a sixth degree black belt with over 40 years of experience. He is a seven-time Long Beach International Karate Tournament Champion as well as a karate tournament trainer. Mr. Salinas specializes in children’s classes and also teaches the P.A.L. program. He has been instructing at St. John’s since Fall 2006.

Mr. Salinas also offers private classes for those interested in one-on-one training.

� Fall classes begin TUESDAYS, 4:00PM to 5:00pm beginners

� FRIDAYS 4 to 5:00pm

� COST :$45.00 A MONTH ONCE A WEEK OR $65 for TWICE A WEEK Half off for second class or second person enrolled. bring a friend and have a great time

� Location: ZION LUTHERAN CHURCH AND SCHOOL 1244 Cypress Street Anaheim, CA 92805-3363

� Uniform Fee: $25 (If you don’t have one.)

For More Information: email: jessektl88@sbcglobal.net

Phone: Mr. Salinas @ 949-514-5136

**Regular SAC fees apply**