MMI Defense New Student Application and Waiver Seminar Name_______________________ Seminar Date____________________ Student’s Name____________________________________DOB______ Date ________ Responsible Adult’s Name_______________________________Relation____________ Address Street_____________________________________City____________State___ZIP____ Phone________________________________ Cell Phone ________________________ E-mail _________________________________ Does the student have any medical conditions or allergies that the instructor should be aware of? No___ Yes___Explain_____________________________________________ ________________________________________________________________________________________________________________________________________________ Emergency Contact Name_____________________________ Phone_____________ Relation___________ I am fully aware that MMI Defense will provide quality instruction and supervision and that MMI Defense shall not be held responsible for any mishaps or accidents. I hereby acknowledge that MMI Defense is not responsible for any injuries suffered while participating in class or utilizing techniques learned in class elsewhere. MMI Defense reserves the right to dismiss any student at any time. Signature__________________________________________________Date__________ Optional Information How did you hear about us? What are your main reasons for learning Krav Maga?