H.M.D. ACADEMY
CHICAGO

Introductory Waiver Form

If you are further interested in H.M.D. Academy, you may participate in two free introductory lessons. This will provide you with some martial arts experience, an understanding of the cooperative atmosphere of H.M.D. Academy and some reference points to recognize if your are researching other programs. It will also allow us to meet one another and through our workouts, I will be able to recommend a program that would best suit you.

Please fill out the below email form and include your phone number. I will contact you to schedule your two free introductory lessons. Thanks you and I look forward to our meeting.

-Blair Sarkis
Instructor

Participant(s) Taking Class:
Last Name: First Name: Date of Birth:
Last Name: First Name: Date of Birth:
Last Name: First Name: Date of Birth:
Address: City/State: Zip Code:
Home Phone: Employer: Work Phone:

Complete if Participant is a minor - Parent/Guardian:
Last Name: First Name:
Address: City/State:
Zip Code:  
Home Phone: Emergency Phone:
Employer: Work Phone:

One of the main benefits of the H.M.D. System is our willingness and ability to work directly with you on any or all concerns you may have. Please check over the list below and mark the line by your appropriate concerns. In the spaces below, rank the five areas which most apply to you, with one indicating the highest priority.

School Work Self-Defense
Relationship / Respect Emotional (Self-Esteem)
Responsibility (Self-Discipline) Fun / Social
Behavior Art Itself
Physical Fitness Learn Skill /Coordination
Relaxation / Stress Management Inter-cultural Experience
Living up to Potential Focus

I understand that by signing/sending this agreement, I am entitled to participate in an introductory Tae kwon Do lesson through H.M.D. Academy at no cost. If this is for a minor or dependent child, my signature grants permission for their participation in this introductory offer.

I, the undersigned, further do hereby, for myself, heirs, and assigns, release and hold harmless H.M.D. Academy, including, but not limited to, its officers, employees and instructors, for any damages or injury sustained or caused as a result of participation in any class, event or special promotion held through any H.M.D. Academy.

Date:
Participant Name:
Parent/Guardian:
Email: