KARATE CLASSES

Instructor: Morris “Spider” Kennedy 330-937-0080

Monday, Wednesday, & Friday
5PM – 7PM Ages 5+

Student Name:_________________________________________________________________
Phone: Home _______________________________ Cell: _________________________
Birth Date: ____________________________________________________________________

Parent’s Name: ________________________________________________________________

Phone: Home _______________________________ Cell: _________________________
Street Address: ________________________________________________________________
City__________________________________________ Zip Code________________________
Allergies/Medical Condition(s): ___________________________________________________
_____________________________________________________________________________
Medications: __________________________________________________________________
Doctor Name: ______________________________ Doctor Phone: ______________________
I understand that reasonable care will be given for my child by Heart Reach Neighborhood Ministries Staff
and volunteers and give permission for emergency medical treatment in case of accident or illness if I cannot
be reached by telephone first. I agree to hold Heart Reach Neighborhood Ministries, volunteers, and staff
harmless for accident, injury, illness, theft or counseling which may occur as a part of this program. I give
permission for photographs or videos of my child to be used without charge for publication, promotion or
advertising purposes if such occasion should arise.

Parent Signature: ___________________________________________ Date: ______________

Heart Reach Neighborhood Ministries  211 Redondo Road  Youngstown, Ohio 44504
Office: 330.744.2000 Fax: 330.744.8116