Outreach Programs for America's Youth... Self-Defense
Registration Form		 Hi

(Please print a copy of this form and bring it to class 15 minutes prior to your class time.)
 (click here when done printing form)

Location:
Class Fees & Ordered Equipment
Day of Class:
Registration Fee: $5.00
Class Time:
Class Fee: $___.00
Start Date:
Total: $___.00
Payment Type: Pre-Paid
Instructor:

Please make checks payable to "Champion Youth", or you may pay with cash.  Correct change is appreciated!

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I, THE PARENT OR GUARDIAN OF THE STUDENT LISTED BELOW, DO HEREBY AGREE TO RELEASE ALL LIABILITY AND CLAIMS, AGAINST CHAMPION YOUTH OUTREACH PROGRAMS INC., AND AGREE TO HOLD HARMLESS, ANY LIABILITY AGAINST CHAMPION YOUTH OUTREACH PROGRAMS INC., ANY SPONSORING ORGANIZATION, FACILITY, INSTRUCTOR, AND ANY OTHER PARTY INVOLVED, DUE TO ANY INJURIES, ACCIDENTS, NEGLIGENCE, OR ANY OTHER CIRCUMSTANCE ARISING FROM PARTICIPATION IN THIS YOUTH RECREATION PROGRAM OR C.Y.O.P. SPONSORED SPECIAL EVENT, WITH RESPECT TO ANY TIME PRIOR, DURING AND AFTER CLASS.
Location:________________________________________ Session: F    W   SP   SU
Student: , Age: School:
Address: Home Phone: ()
, Work Phone:

If your child has a medical condition or disability that the instructor should be aware of, please let them know.

Parent: Signature:
Date:

Parent Helpers Only

Please fill out this section as accurately as possible.

Thank You!
Check!Rec Payment Type
Registration Fee: $5.00 _____
Class Fee: $____.00 _____       Cash [  ]
__________________ _______ _____
__________________ _______ _____       Check
__________________ _______ _____      #_________
Total Paid Today: $____.00 _____

(click here when done printing form)