Any previous experience in Martial Arts? ______yrs or Aerobics? _____yrs

If yes, how many years of experience have you had? ______________________

Payment: ____ Check (Made out to IFKA) ____Cash

____ Master Card ____ Visa ____ American Express

Credit Card Number: ________________________________ Exp. Date: ______/_____

Payee’s Signature: _________________________________________________

If you are paying by credit card, you can fax your registration to IFKA: (954) 587-5077.

I,_______________________________________, city of _____________________, state of _________, am aware of all of the inherent dangers of Kickboxing training. I understand and agree that IFKA, Funkicks(TM), the American International Karate Institute, the University Center, ISKA, Rodrigo Navarrete or Robert H. Mason may not be held liable in any way for any occurrence in connection with Kickboxing training which may result in harm or serious injury to me.

In consideration of being allowed to enroll in this course, I hereby personally assume all risks in connection with said course, and I further release the above instructor, program, agents, and operators, including the owner of the facility, but not limited to the persons mentioned, for any harm, injury, or damage which may occur to me while I am enrolled in the IFKA program, the American International Karate Institute, International Fitness Kickboxing Association, FunkicksTM, Rodrigo Navarrete or Robert H. Mason, including all risks connected herewith, whether foreseen or unforeseen, and further to save and hold harmless said program and person from any claim by me, or my family estate, heirs or assigns, arising out of my enrollment and participation in this kickboxing course.

I further state that I am of lawful age and legally competent to sign this consent and release, or, if I am a minor, my parent or guardian herein consents to my enrollment in this course and adopts this release in my stead. I also understand that the terms herein are contractual and not a mere recital, and that I have signed this document of my own free act.

I have read the contents of this release before signing it. I have either had a medical examination, or I have assumed my own responsibility to assure myself of physical fitness and the capacity to perform under the normal conditions of a Kickboxing program.

I give permission for the use of my photograph, likeness or video image for any purpose by IFKA and the American International Karate Institute. I understand that any and all qualifications issued as a result of satisfactory completion of a workshop remain the property of the IFKA. Such qualifications may be withdrawn if program policies are violated.

__________________________________________Student, Parent or Guardian (if under eighteen) ______/______/______Date