Beyond Karate Adult Program Application
Beyond Karate Studio
2358 Pico Blvd., Santa Monica, CA 90405
Contact us at (310) 896 - 8461 or info@beyondkarate.org
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Beyond Karate must receive this form, which includes waivers, before the start of any program with Beyond Karate.
**ALL fees and/or funding authorizations are due upon registration to secure your attendance.**  
Full name, followed by preferred nickname, if applicable: *
Date of birth (must be over 18 to complete this form): *
Age:
Gender and preferred pronouns:
Contact Number: (3101111111) *
Email:  *
Home address: *
EMERGENCY CONTACT:

Full Name + Relationship:
 *
Contact number: (3101111111) *
Form of Payment for Services: *
If you chose "Self Determination" as form of payment, please specify which agency:
If you chose "Regional Center" as form of payment, please specify which one and your coordinator's name and contact information:
Do you have a history of seizures? (If YES, a Seizure Action Plan must be completed PRIOR to the 1st day)
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What is your type of work or study?
What are your main areas of interest and favorite activities?
What are your goals for participating in any of our programs?
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Does you have any triggers we should be aware of?
Is there any other information you would like to share with us that may be helpful for our instructors to know?
In consideration of Beyond Karate providing me with training in karate and/or any other activities upon the assigned premises or property of the karate school, the undersigned hereby assumes any and all risks of injury and hereby releases and discharges Beyond Karate, its officers, agents, and employees, from all liability to the undersigned, his/her employer, assigns and personal representative for any loss or damage, and any claim or damage therefore, on account of injury or other casualty to the person or property of or in the possession or control of the undersigned, whether due to the negligence of or otherwise said Beyond Karate, its officers, agents, employees or licensees, or by fellow students while the undersigned and/or such property is upon the premises of Beyond Karate or while the undersigned is a participant in any other location, exhibition, demonstration, or contest.
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I authorize Beyond Karate staff members to take photos and/or video footage of clients for client file, advertising/marketing purposes to include, but not limited to, print, signage, website, and/or social media. I hereby release and discharge all employees of Beyond Karate from liability to me for all losses, damages, and expenses and injury to person or property, including death, resulting from participation in the program. It is further understood by the undersigned that Karate is an art involving physical combat and that I may sustain personal injury, and therefore the undersigned hereby assumes the risk of any injury which one might sustain while being trained on the premises of Beyond Karate and/or during exhibitions, demonstrations, contest, or outdoor training.
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Written notice must be given to Beyond Karate 30 days prior to the decision to stop attending scheduled sessions along with the payment due for that 30-day period. If written notice is not received, the undersigned will be billed for the 30 days period and responsible for payment.
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Please note that once you have booked an appointment with us it means that we have reserved time in our schedule exclusively for you. Cancellations made less than 24 hours before a scheduled appointment or session, will be subject to a cancellation fee in the full amount of your scheduled session. Unless you provide payment otherwise, your credit card on file will be automatically charged, with an additional surcharge fee (3.5%). If we are unable to process your credit card on file, an additional $25 will be added to the cancellation fee. If you are funded through the Regional Center or Self Determination, you will be personally liable for all cancellation fees for cancellations under 24 hours before scheduled sessions and your credit card on file will be charged for the penalty fee. To avoid a cancellation fee, please provide a cancellation notice a minimum of 24 hours prior to your appointment by texting or calling (310) 896-8461. If you are discontinuing sessions at Beyond Karate, we must receive a 30-day written notice prior to the last scheduled session. If written notice is not received, the undersigned will be billed for the 30 days period and responsible for full payment.
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Please be mindful of others when attending any program at Beyond Karate. If you are showing signs of sickness (i.e., covid, fever, chronic cough, runny nose etc...) We do reserve the right to send individuals home if we feel they are too sick to be at our facility that day. Please be mindful that sick days do not reduce tuition.
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Volunteer
Beyond Karate believes in the strength of community and values involvement. 

What are some of your strengths/skills/interests/talents you would like to share and what ways would you be interested in participating?
How did you hear about us? Please check all that apply
Opt In for text communication regarding scheduling, questions, events, etc. Please understand that message and data rates may apply. *
Required
I have thoroughly read and acknowledge the above Beyond Karate policies.
I have read and acknowledge this application and waiver to completion.
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Full name:
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Today's date: *
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