Participant's Name *

First Name

Last Name

Parent/Legal Guardian

If student is under the age of 18

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

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Birth Date *

Participant's Date of Birth

MM

DD

YYYY

Warning, Waiver, Release of Liability, Assumption of Risk and Agreement to Participate *

THIS AGREEMENT MUST BE ELECTRONICALLY SIGNED PRIOR TO PARTICIPATION IN ANY NATIONAL ASSOCIATION ANNUAL SEMINAR SANCTIONED EVENTS AND TRAINING. In consideration of being allowed to participate in any way in the sanctioned events and training of the National Shorei Goju Ryu Association, I, 1. Recognize and understand that martial arts training is a physical contact activity and that my participation might result in serious injury, including permanent disability or death, and severe social and economic loss. 2. Recognize and understand that such risk may be due to not only my own actions, but also the action, inaction or negligence of others, the regulations of participation, or the conditions of the premises or of any of the equipment used. 3. Recognize that there may be other risks that are not known to me or to others or not reasonably foreseeable at this time. 4. Agree to inspect the facilities, equipment and pairings prior to participation. I will immediately inform an instructor if I believe that anything is unsafe or beyond my capability and refuse to participate. 5. Assume all of the foregoing risks and accept personal responsibility for any damages that may result from injury, permanent disability or death. 6. Enter martial arts training and/or competition entirely of my own free will and understand the importance of following the rules of training and competition. I have been given a copy of the rules and regulations of National Shorei Goju Ryu Association and agree to abide by the instructions given therein. 7. I certify that I am in good physical condition, and have no disease, injury or other condition that would impair my performance or physical and mental well-being during intense training practice and/or competition. 8. I agree to use my personal medical insurance as a primary medical coverage payment if accident or injury occurs. I grant permission in case of injury to have a doctor, nurse; athletic training or other emergency medical personnel provide me with medical assistance or treatment for such injury. 9. Release, waive, discharge and covenant not to sue, Lebanon Martial Arts Academy, its affiliated organizations and governing bodies, their officers, instructors and personnel, other members of the organizations, participants, supervisors, coaches, sponsoring organizations or their agents, and if applicable, owners and leasers of the premises from any and all liability to the undersigned, his or her heirs and next of kin for any and all claims, demands, losses and damages which may be sustained and suffered on account of injury, including death or damage to property, caused or alleged to be caused in whole or in part by the negligence of the releases or otherwise. 10. I agree that photographs, pictures, slides, movies, video, or other media coverage of my/minor may be taken in connection with my/minor’s participation in the activity without compensation and consent to the use of photographs, pictures, slides, movies, videos, or other media coverage for any legal purpose.

I HAVE READ THE ABOVE WARNING, WAIVER, RELEASE AND AGREEMENT TO PARTICIPATE. I UNDERSTAND ITS CONTENTS AND DO HEREBY CHECK THIS BOX AS AN INDICATION OF THE ABOVE AND THAT I AM DOING SO VOLUNTARILY.

ELECTRONIC SIGNATURE *

I HAVE READ THE ABOVE WARNING, WAIVER, RELEASE AND AGREEMENT TO PARTICIPATE. I UNDERSTAND ITS CONTENTS AND DO HEREBY GIVE THIS ELECTRONIC SIGNATURE AS AN INDICATION OF THE ABOVE AND THAT I AM DOING SO VOLUNTARILY.

First Name

Last Name

Today's Date

MM

DD

YYYY

Payment Submitted

Please submit your payment to your Sensei. Thank you!

YES

Dojo Affiliation *

Blade Family Martial Arts Academy

Broad Ripple Martial Arts Academy

Family Karate Academy USA

Frank Harness Karate USA

Hernly Family Karate

Jeanie Gensheimer Martial Arts

Lebanon Martial Arts Academy

Lion & Lamb Family Karate USA

Massey Martial Arts Academy

Matt Galvin Karate USA

Phil Morgan Karate USA

Phoenix Rising Karate

Stone Tiger Dojo

Unaffiliated Dojo