BJSA / ATA Martial Arts Class Registration

Students Name:_________________________________________ Age:______________

Address:___________________________________ State:______ Zip:______________

Hm. Phone:___________________________ Cell. Phone:__________________________

Email Address:__________________________________________________________________

Parent’s/Legal Guardian:__________________________________________________________

Emergency Contact:____________________________________ Phone:__________________

School:___________________________________ DOB:_________________________

I hereby give my permission for my child to participate in the Bellevue Junior Sports Association / ATA Martial Arts Classes. I release Bellevue Junior Sports Association and ATA from all liabilities due to accident or injury and I do myself assume this responsibility. I also grant permission to BJSA / ATA Officials to authorize and obtain medical care from any licensed physician, hospital, or medical clinic should my child become ill or injured while participating in the above Martial Arts Classes.

______________________________________________ _______________________

Parent/Guardian Signature Date

NOTICE: LEGISLATIVE BILL 594 enacted by the Nebraska State Legislature in 1989 states the

Following: Coaches, managers, umpires, referees, their assistants, or anyone who

Prepares any playing fields shall NOT be liable for the injury or death of any participant

In the BJSA/ATA Martial Arts Classes which results from the negligence of any of the

Above listed individuals.

Negligent act or omission shall not include any reckless, willful, wanton, or grossly

Negligent act or omission.

**NO REFUNDS WILL BE ISSUED AFTER THE FIRST CLASSES HAS BEEN COMPLETED.