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Membership Application


PeopleSafe® Online Membership Application
Adult Members Only

Membership Type

New     Renewal
 
Personal Information
First Name
Last Name
Street Address
City
State
Zip Code
Home Phone No.
Email Address
Date of Birth
Sex male     female
Occupation
Work Phone No.
Emergency Contact
Phone

Character Reference 1
Phone
Character Reference 2
Phone
Do you have any physical or emotional impairments? yes     no (if yes, we may ask you to clarify)
Have you ever been charged or convicted of a felony?? yes     no (if yes, your application may be denied)
Are you on any medications? yes     no (if yes, we will ask you to clarify)
  
Martial Arts Experience
Last Dojo you belonged to
Instructor
Style Rank Date  Dojo
How did you hear about us?

word of mouth
yellow pages
saw sign
referred by a member
Was a prior member
Internet website
Note:  For recognition of rank, documentation in English must be provided.

 

Dojo Creed

* I will train faithfully to strengthen my mind and body.
* I am willing to endure rigorous training to achieve my goal.
* As my strength increases I shall seek to cultivate a gentle heart.
* I will not use my skill outside the Dojo, except in the most extreme circumstances.
* At all times I will try to avoid inflicting injury upon another person.
* I will not brag about my skill nor will I use it maliciously.
* I will train with the spirit of humility. 

Make Checks/Money orders payable to: Phil Rasmussen 
and return this form and remittance to:

          PeopleSafe®  
          521 Starmount Lane
          Hendersonville, NC 28791

GENERAL RELEASE OF RESPONSIBILITY (must be signed in presence of instructor)

I Certify that I have been made aware of potential hazard involved in martial arts and training for self defense. I am physically fit and have no medical condition which would preclude me from participation in these activities. I understand that during the course of instruction, PeopleSafe® Instructors and/or other members or authorized persons will be engaged in a course of conduct requiring physical contact; and I give full consent to such contact as is required by the training. The undersigned agrees that PeopleSafe®, its agents, members and employees, shall not be responsible for accidents or injuries of any kind, whether the same shall be caused by or attributable to their negligence or the negligence of any of them or otherwise. The undersigned shall indemnify and same harmless PeopleSafe®, its agents and employees, against all damage, loss or expense which they or any of them incur as a result of any claim or action which may at any time be made or instituted on behalf of the above named member including, without being limited to, any claim or action based upon the negligence of PeopleSafe®, its agents, members or employees.

I promise to uphold the principals, ideals and regulations of PeopleSafe®. I acknowledge that my membership is voluntary and subject to review by PeopleSafe®. 

    By this check, I certify, to the best of my knowledge, that the information in this application is true and accurate.  I understand that if, upon review of this application, or anytime thereafter, it is revealed that I have made any false statements, my membership will be terminated without delay or refund. Submission of this application does not guarantee enrollment. PeopleSafe® reserves the right to accept or decline applicants. I understand that I must sign this application before being allowed to participate in any PeopleSafe® activities.  

Further, I understand that by submitting this information via electronic transmission that I acknowledge the above statement of certification in lieu of a signature.