Date_____________

Student's Name:___________________________________________________________

                            (Last)                                                       (First)                                      (MI)

Address_________________________________________________________________

City__________________________________. State_________ Zip Code_____________

Home Phone Number___________________ Birth Date_____________ Age__________

In case of emergency call__________________________________Phone #___________

Please list any health problems the student may have______________________________

________________________________________________________________________

I understand that I am responible for paying each month's tuition the first of each month.

I understand that I will have to pay a $5.00 late fee if tuition is not paid by the tenth of the month.

I hereby waive and release Dwayne E. Scott, Jane Scott, Scott's American Martial Arts, students or instructors from any and all liability for any injuries incurred while participating in class or activities.

Student signature:________________________________________Date:______________

If student is under 18 years of age, the parent or guardian must sign slip:

________________________________________________________________________