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Student Information and Release Form

Name*

Demographics

Sex*

Male

Female

Birthdate*

Contact Information

Email*

Phone*

Address Line 1

Address Line 2

City

State

ZIP

Other Information

Do you have prior martial arts experience?

Do you have any medical conditions we should be aware of?

Release and Waiver

Karate and martial arts instruction is a physical training regimen that can, at time, result in injury to the practitioner. This informational disclaimer is intended to inform you, as a student, and your parents if you are under the age of 18 years, of that fact. All care during instruction will be taken to avoid injury and all efforts will be toward safe training. The student (and parents if the student is under 18) assumes full responsibility for any injuries or damage which may occur to the student and does hereby fully and forever release and discharge the , the All Okinawa Shorin-ryu Karate and Kobudo Federation, the Okinawa Shorin-ryu Matsumura Seito Karate and Kobudo Federation, , Fusei Kise, Isao Kise and any other owners, representatives, officers, servants, agents, or members from any and all claims, demands, damages, rights of action, or causes of action, present and/or future, whether the same be known or unknown, anticipated or unanticipated, resulting from or arising out of the students use or intended use of said school facilities, members, and equipment thereof, without limitation, any claims for personal injuries resulting from or arising out of the negligence of school, its officers, representatives, servants, agents, or members.

Parents are encouraged to attend classes and observe the training practices at this dojo. It functions both as an opportunity to see what is being taught to your child and to answer any questions you may have regarding the class, the instruction, and the quality of training your child is receiving.

I have read and understand the preceding two paragraphs above as well as the handbook, rules and regulations, and agree to receive instruction or allow my children to receive instruction under these conditions and at my own risk:

Student Signature*

Sparring Policy

This policy is written to inform the students and participants of the school rules regarding grappling, locking, trapping, and free sparring.

Students are not required to free spar at this school and do so of their own free will.
Students will be required to have their own personal safety gear for sparring to include at a minimum
1. Head protection (full face gear is mandatory for youth students
2. Hand and Foot protection (youth)
3. Groin protector (males)
4. Mouthpiece
5. Additionally, any safety equipment the student deems necessary for his or her protection may be worn. It is highly encouraging that chest protectors are worn by female students.
In addition, the following is required for the combative classes
1. Foam shin/ instep guards (cloth is not allowed)
2. Boxing gloves (16 oz)
3. Open finger sparring gear
4. Groin protector (males)
5. Mouthpiece
Worn and ragged safety equipment with torn or sharp edges is not allowed.
It is not required to purchase equipment from the dojo, but the equipment you select MUST be approved by the Chief Instructor before it is allowed to be used.
Only light or non-contact sparring is allowed during free sparring sessions. Full contact or heavy contact sparring must be under a totally controlled environment. This statement, in no way, implies that contact will not occur during the course of a free-sparring match.
Free sparring is not allowed unless the Chief Instructor () is present at the school.
No contact is allowed to head, face, neck, spinal area, or groin (except for light contact to protective gear).
Contact to joints such as knees and elbows, is not allowed.
If a student is injured during free sparring, the Chief Instructor is to be informed at once
Effective date of this policy is 1/1/2010.

Signature of Sparring Release

By signing below, the student (or the parent/guardian of the student if the student is under 18) acknowledges the above policy and affirms that they will follow protocol while sparring at .

Student Signature*

Student/School representations and release of liability:

Student/parent/guardian acknowledges that they should have received permission from a medical doctor following a general physical examination approving the student’s participation in any martial arts program:*

The member applying warrants and represents that he/she/minor or student is in good physical condition and has not been advised by any Physician or Medical Facility that participation in martial arts training will in any way be averse to the wellbeing of the student. Furthermore, member represents that the student is able and allowed to participate in exercise and various martial arts curriculum which is provided by

Student/parent/guardian understands that by participating in the martial arts program or by use of the facilities or equipment covered by this contract does present the possibility of accidental injury, disability, paralysis, or death. Student/parent/guardian assumes all risk associated with such participation within this program and holds harmless for any such injury or occurrence. In addition, student/parent/guardian agrees to indemnify from any and all liability which may arise against by such member or through any other third party as a result of training received by or by use of the facilities or equipment of *

Student/parent/guardian understands that during instruction, employees or higher degree student instructors of will be engaged in a course of conduct requiring physical contact, and he/she (or parent or guardian) gives full consent to such contact as is by the training.*

It is understood that due to the nature of the training which is being provided by that accidents do from time to time occur. While all precautions will be taken to assure the safety of all students, it is impossible to foresee all risks or to guarantee that such accidents will not occur. Student/parent/guardian agrees to hold harmless in the event of any such accident and further agrees that neither they nor any other financially responsible person will take action against as a result of such injuries unless caused due to negligence.*

Student/parent/guardian understands that this 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 any activities or demonstrations of the martial arts classes of are conducted and that if any portion is held invalid, it is agreed that the balance shall, not withstanding, continue in full legal force and effect.*

Student/parent/guardian understands that if, despite this release, a claim is made by the participant, or on his behalf, against , the student/parent/guardian will reimburse for any money that has been paid to the participant, or on his behalf, and hold harmless.*

By signing this consent, you give your permission to have your video or photo taken during any class or seminar you choose to attend. If you desire not to have your photo or video taken, you agree to remove yourself from the field of view of the camera:*

By signing this contract, you are certifying that you are either of legal age or that you are signing this contract as the parent or legal guardian of a minor, and by signing this contract on behalf of any minor, you hereby agree that you shall be responsible for all payments due hereunder and that you will indemnify and hold harmless for any injuries, losses, or damages sustained to anyone as a result of the minor’s participation in this program of instruction.*