Namido Martial Arts Organization
Fall Seminar 2010
Registration Form-Complete and return (please print)
Name: __________________________________________
Parent’s name if under 18:___________________________
Date of Birth: _____/______/_______
Address: __________________________________________
_________________________________________________
Phone Number :( )_____-_______
Instructor’s Name: ____________________________________
Name of Dojo: ______________________________________
Style: ___________________________________________
Rank: _________________________________________
Any health conditions or physical limitations that we need to know about: ________________________________________________________________________________________________________
Any allergies? ________________________________
In case of emergency contact: __________________________
Telephone: (_____) _______-_________
Cell: (_____) ______-_________
Namido Member? : Yes ___ or No ___
------------------------------------------------------------------------------------
Waiver Received? : Yes ___ or No ___
Deposit Paid? : Yes ___ or No___
INDIVIDUAL WAIVER AND RELEASE OF LIABILITY
(THIS DOCUMENT IS IMPORTANT, SHOULD BE READ IN ITS ENTIRETY, AND SIGNED)
In consideration of being allowed to participate in any way in the Namido Martial Arts Org. athletics/sports program, and related events and activities, the undersigned:
1. Agrees that prior to participation, he/she will inspect the facilities and equipment to be used, and if he/she believes anything is unsafe, will immediately advise his/her coach or supervisor of such condition(s) and refuse to participate
2. Acknowledges and fully understands that he/she will be engaging in activities that involve risk of serious injury, including permanent disability and death, and severe social and economic losses which must result not only from his/her own actions, inactions, or negligence of others, the rules of play, or the condition of the premises or of any equipment used. Further, that there may be other risks not known or not reasonably foreseeable at this time.
3. Assumes all the foregoing risks and accepts personal responsibility for the damages following such injury, permanent disability or death.
4. Releases, waives, discharges, and covenants not to sue the Namido Martial Arts Org., its affiliated clubs, their respective administrators, directors, agents, coaches and other employees of the organization, other participants, sponsoring agencies, to conduct the event, all of which are hereinafter referred to as “releases”, from the demands, losses or damages 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 release or otherwise.
I HAVE READ THE ABOVE WAIVER AND RELEASE, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND SIGN IT VOLUNTARILY. THIS FORM WAIVES LIABILITY FOR NEGLIGENCE. THIS AGREEMENT CANNOT BE MODIFIED ORALLY.
____/______/______ _______________________________________
(Date) (Print Name)
__________________________________________________________
(Signature/Signature of Parent/Guardian if under 18 yr.)