This form is only intended for students that have paid their affiliation fee. If you wish to enquire about our dojo, please use the following: Enquire Now

Student Information


Person Responsible for Account


Medical Information


Disclaimer


In consideration of being allowed to participate in any way in the above listed club sport, related events and activities, I, the undersigned, acknowledge, appreciate and agree that:

  1. The risk of injury from the activities involved in these sport events is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce the risk, the risk of serious injury does exist; and
  2. I knowingly and freely assume all such risks, both known and unknown, and assume full responsibility for my participation; and
  3. I willingly agree to comply with the stated instructions and policies and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official or instructor immediately; and
  4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release, indemnify and hold kime KARATE, and their officials, owners, instructors, agents and/or employees, other sport participants, sponsors, advertisers, and, if applicable, owners and lessor of premises used to conduct the event or activity (“Releases”) harmless with respect to any and all injury, disability, death, or loss or damage to person or property, to the fullest extent permitted by law.
  5. I understand, agree and acknowledge that some activities may be of hazardous nature and/or include physical and/or strenuous activity. Understanding this, I state that I have no medical condition or impairment that might inhibit my safe and active participation in the above listed activity. In addition, I understand that kime KARATE does not provide medical insurance coverage and that medical insurance must be provided individually by such participants. In the case of injury or medical emergency and in the event participant, or their parent or guardian, cannot respond at the time of the emergency, kime KARATE has permission to see, administer, or have administered whatever first aid or emergency medical care deemed necessary for participant’s welfare, and it is understood that the participant, and not kime KARATE, shall be responsible for any and all charges for such health care services regardless of whether participant’s medical insurance would cover such charges.

    Please Note

    • 30 days written notice is required on cancellation of membership.
    • No seasonal discounts are provided and the student is liable for the full year’s membership.

    I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT

(If participant is under the age of 21, parent/legal guardian signature)