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65 Water Street
Worcester, MA
01604

Check out our new Iaido program!


Check out our new Aikido Morning classes!



 

Contact Information:
First Name:  
Last Name:  
DOB:   / / mm/dd/yyyy
Gender:   Male: Female:
Address:  
City:  
State:  
Zip:  
Home Phone:  
Work Phone:  
Email Address:  
 
Person to contact in case of emergency:
Primary: First Name:  
Last Name:  
Phone:  
Secondary: First Name:  
Last Name:  
Phone:  
 
Program:
Zenshinkan Program:  
Anticipated Start Date:   / / mm/dd/yyyy
Tuition or Fee:  

DISCLAIMER OF LIABILITY AND RELEASE OF ALL CLAIMS
By submitting this form, the applicant desires to participate in the above activity with full and complete knowledge of the possibility of incurring bodily injury in the course of such study. The applicant, therefore, in consideration of being accepted as a participant in such study by Zen Training Center, Inc. / Zenshinkan Dojo at 65 Water Street, Worcester, Massachusetts 01604, or other locations occupied by Zen Training Center, Inc. / Zenshinkan Dojo hereby assumes all risks of bodily injury (whether anticipated or unanticipated) resulting from his/her participation in the study and practice of the above listed activity. The applicant further agrees to hold harmless Zen Training Center, Inc., / Zenshinkan Dojo, its officers, instructors, and agents, as well as leaser Michael Komenos of 125 Barber Ave., Worcester, Massachusetts from all loss, liability, claim or expense (including reasonable attorneys fees) arising from bodily injury as a result of the applicant’s study and practice of the above listed activity.

I have read, understand and agree to the above DISCLAIMER OF LIABILITY AND RELEASE OF ALL       CLAIMS

 
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