古典剣術保存協会 DENTŌ KENJUTSU HOZON KYŌKAI — MEMBERSHIP APPLICATION Hakuhi Yauco Michi Dojo | Code: PR02 $______ Dojo Registration Fee $______ Dojo Monthly Fee $100.00 D.K.H.K Membership Fee PERSONAL DATA First Name * M.I. Last Name * Date of Birth * Place of Birth Marital Status Select... SingleMarriedDivorcedWidowed Age Gender --MaleFemaleOther Weight Height Eyes Color Residential Address * City State Zip-code Home Phone # Additional Phone # Postal Address (if different) City State Zip-code Closest Relative Relationship Relative Phone # Additional Phone # Applicant's Job (School if Student) Job's Address (School) Job's Phone # Additional Phone # MARTIAL ARTS HISTORY Entry 1 Date Start (Month & Year) Martial Art Form & Style Rank Achieved Rank Date Instructor Instructor's Rank Organization Organization Address City State Zip-code Entry 2 (if applicable — leave blank if not needed) Date Start (Month & Year) Martial Art Form & Style Rank Achieved Rank Date Instructor Instructor's Rank Organization Organization Address City State Zip-code All applicants must present evidence of identification.Black Belt holders must present Martial Arts Resume & Photocopy of Ranks. Upload ID / Resume / Rank Certificates (optional — or bring in person) PROPERTY COPYRIGHTS AGREEMENT I, the applicant, understand and agree to all rules, regulations and procedures of the DENTŌ KENJUTSU HOZON KYŌKAI and of Hakuhi Yauco Michi Dojo; which clearly establish that all material of Martial Arts given to me by the previous mentioned institution, as of any of its components, is private material to which its lawful owner is exclusively the headmaster and not, under any circumstance, my property. I also understand and agree that said private material includes the DENTŌ KENJUTSU HOZON KYŌKAI and its components or parent entities: names, entity, logos, emblems, styles, and/or positions. In addition, unless I am officially authorized and licensed by the headmaster, I am NOT authorized to teach, instruct, and/or represent said institution. Furthermore, I shall NOT share and/or publish private property information without proper written authorization. I have read and agree * Initials: PHOTO & IMAGE CONSENT I authorize the DENTŌ KENJUTSU HOZON KYŌKAI and Hakuhi Yauco Michi Dojo to use photographs, video recordings, and/or other images of me taken during training sessions, events, and activities, for educational, promotional, and social media purposes, without compensation. I AUTHORIZE I DO NOT AUTHORIZE Initials: RELEASE OF RESPONSIBILITIES I, the applicant, release of all responsibility the DENTŌ KENJUTSU HOZON KYŌKAI and its partners, including: Board of Directors, Representatives, Instructors, Assistant Instructors, International Members and Hakuhi Yauco Michi Dojo, and/or any other Component and/or Affiliate; of any injury, wound and/or physical, mental and/or emotional harm received during and/or as consequence of any training and/or activity or event related to martial arts. I also understand and agree that this institution shall always have the right to suspend or terminate my membership, and/or take disciplinary actions against me for any action or behavior that could be considered illegal, immoral, and/or dishonorable. I have read and agree * Initials: The DENTŌ KENJUTSU HOZON KYŌKAI and its representative the Hakuhi Yauco Michi Dojo is a private Martial Arts educational institution. This institution withholds the rights to accept and/or reject any applicant. By submitting this form, the applicant declares that they understand and agree to everything stated above, including the Property Copyrights Agreement, the Photo & Image Consent, and the Release of Responsibilities. SIGNATURE Type your full legal name as your digital signature * Date * By typing your name above, you are signing this application electronically and confirming that all information provided is true and accurate. LEGAL CUSTODIAN DATA — Required if applicant is under 21 Fill out this section only if the applicant is under the age of 21. Otherwise, leave it blank. Legal Custodian's Full Name Relationship to Applicant Custodian's Home Phone # Additional Phone # Identification Type (e.g. Driver's License, Passport) ID Number Custodian's Address City State Zip-code Custodian's Signature (type full legal name) Date Submit Application * Required fields. Your application will be reviewed by Hakuhi Yauco Michi Dojo staff before approval.
