Registration Form

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Emergency Contact Information
(Who we should contact during class if you are not available)
Agreement

Student(s) certifies the he/she is in good health and has received regular medical care during the last year, and that there is no reason that he/she knows of that strenuous, rigorous activity would be unsafe.

PVMA agrees to provide expert, professional instruction by Charlie DiGirolamo, 6th Degree Black Belt, certified by the Pan American Han Moo Kwan Tae Kwon Do Federation, Level 3 Certified KKM Instructor, and members of PVMA staff.

Student(s) agrees to abide by the rules of PVMA, specifically, but not limited to, those relating to the safety of the Student(s) and others. Student(s) agrees to refrain from using the knowledge obtained from PVMA for any compensation, without expressed written consent, during training at PVMA, and for a period of two (2) years after training with PVMA.

Student(s) understands that the study of the martial arts is a rigorous discipline and is inherently dangerous. Student(s) agrees to act responsibly at all times in his/her conduct at PVMA. PVMA will have only qualified instructors teach and supervise classes, and will maintain all equipment in good working order.

THEREFORE, STUDENT(S) AND STUDENT'S PARENT(S)/GUARDIAN(S) AGREE TO ASSUME ALL RISK OF PERSONAL INJURY (INCLUDING DEATH) AND PROPERTY DAMAGE WHILE ATTENDING OR PARTICIPATING IN THE STUDY OR PRACTICE OF ANY OF THE MARTIAL ARTS, AND ACTING FOR HIM/HERSELF, HEIRS, PERSONAL REPRESENTATIVES, AND ASSINGS, DOES HEARBY RELEASE PVMA AND ITS REPRESENTATIVES IN ANY CAPACITY, PERSONAL OR OTHERWISE, FROM ALL LIABILITY, INCLUDING CLAIMS AND SUITS IN LAW OR IN EQUITY FOR ANY INJURY, FATAL OR OTHERWISE, WHICH MAY RESULT DIRECTLY OR INDIRECTLY FROM TRAVELING TO, PARTICIPATING IN, OR RETURNING FROM PVMA.

PVMA reserves the right to terminate this Agreement immediately upon written notice should PVMA in its sole discretion deem the Student's conduct is dangerous to him/herself or others.

I have read the PVMA Tuition and Payment Policy and agree to the PVMA terms.

I understand that PVMA implements a 12 month minimum enrollment period, consisting of 12 months or 96 classes (which ever comes first).

I understand that any pre-paid tuition is non-refundable.

PHOTO & VIDEO PERMISSION

By checking box you are giving consent for PVMA to use pictures and videos of your student(s) for advertising and promotional purposes, including PVMA Facebook page, PVMA Instagram page, and PVMA website. 

1614L Union Valley Road, West Milford, NJ 07480.  E-mail: passaicvalleyma@gmail.com

Tel: 973-506-7200

© 2018 by Passaic Valley Martial Arts, Inc.

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