Sign - Student Registration & Waiver Form

Student Registration & Waiver Form - Adult

Student Information

* Name:

Birthday:

* Age:

* Address:

* Primary Phone:

Secondary Phone:

* Primary Email Address:

Secondary Email Address:

* Emergency Contact Names & Numbers:

Medical Concerns or Limitations (and name if multiple students are included on this form):

Miscellaneous Information

Name of the person in the immediate household with military, firefighter, law enforcement, or EMT experience:

How did you hear about Desert Dragons Kenpo Karate:

Previous Martial Arts Experience (style and rank):

Photography/Video Release

Desert Dragons Kenpo Karate would like the opportunity to document our journey together through photo and video. These images may be used for studio events, Desert Dragons website, social sites or marketing.

Please read and agree to the information below:

I/He/She may be photographed or filmed while attending Desert Dragons Kenpo Karate sponsored classes or events. I give permission to Desert Dragons Kenpo Karate, and any affiliates to use any and all photos, video footage, and/or video streaming for promotional, sales, publicity, and advertising purposes for all media including internet. I have read this Photography/Video Release and agree to abide by it.

Yes

Release and Waiver of Liability and Indemnity Agreement

(Read Carefully Before Signing)

In consideration of being permitted to participate in any way in the self-defense program indicated below and/or being permitted to enter for any purpose any restricted area (here in defined as any area where in admittance to the general public is prohibited), the parent(s) and/or legal guardian(s) of the minor participant named below agree:

1.I/WE fully understand and acknowledge that prior to participating in the below self-defense activity or event, I/WE should inspect the facilities and equipment to be used, and if I/WE believes anything is unsafe, the I/WE should immediately advise the officials of such condition and refuse to participate. I understand and agree that, if at any time, I feel anything to be UNSAFE, I will immediately take all precautions to avoid the unsafe area and REFUSE TO PARTICIPATE further.

2.I/WE fully understand and acknowledge that:

a.There are risks and dangers associated with participation in self-defense events and activities which could result in bodily injury partial and/or total disability, paralysis and death.

b.The social and economic losses and/or damages, which could result from these risks and dangers described above, could be severe.

c.These risks and dangers may be caused by the action, inaction or negligence of the participant or the action, inaction or negligence of others, including, but not limited to, the Releasees named below.

d.There may be other risks not known to us or are not reasonably foreseeable at his time.

3.I/WE accept and assume such risks and responsibility for the losses and/or damages following such injury, disability, paralysis or death, however caused and whether caused in whole or in part by the negligence of the Releases named below.

4.I/WE HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the self-defense facility used by the participant, including its owners, managers, promoters, lessees of premises used to conduct the self-defense event or program, premises and event inspectors, underwriters, consultants and others who give recommendations, directions, or instructions to engage in risk evaluation or loss control activities regarding the self-defense facility or events held at such facility and each of them, their directors, officers, agents, employees, all for the purposes herein referred to as “Release”...FROM ALL LIABILITY TO THE UNDERSIGNED, my/our personal representatives, assigns, executors, heirs and next to kin FOR ANY AND ALL CLAIMS, DEMANDS, LOSSES OR DAMAGES AND ANY CLAIMS OR DEMANDS THEREFORE ON ACCOUNT OF ANY INJURY, INCLUDING BUT NOT LIMITED TO THE DEATH OF THE PARTICIPANT OR DAMAGE TO PROPERTY, ARISING OUT OF OR RELATING TO THE EVENT(S) CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE RELEASEE OR OTHERWISE.

5.I/WE HEREBY acknowledge that THE ACTIVITIES OF THE EVENT(S) ARE VERY DANGEROUS and involve the risk of serious injury and/or death and/or property damage. Each of THE UNDERSIGNED also expressly acknowledges that INJURIES RECEIVED MAY BE COMPOUNDED OR INCREASED BY NEGLIGENT RESCUE OPERATIONS OR PROCEDURES OF THE RELEASES.

6.EACH OF THE UNDERSIGNED further expressly agrees that the foregoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as is permitted by the law of the Province or State in which the event is conducted and that if any portion is held invalid, it is agreed that the balance shall, notwithstanding continue in full legal force and effect.

7.I/WE the undersigned student executes this Waiver and Release. If, despite this release, the participant makes a claim against any of the Releases, I/WE will reimburse the Release for any money which they have paid to the participant, or on his behalf, and hold them harmless.

* I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.

Facility: Desert Dragons Kenpo Karate LLC and Instruction Team

* Printed Name of Participant:

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