Participation DeclarationStep 1 of 425%Types of Classes(Required) Kinda Kids Karate - Teens/Adults Karate - Kids Special NeedsDate Joined Day Month Year Name(Required) First Last Date of Birth(Required) Day Month Year Address(Required) Street Address Address Line 2 State / Province / Region ZIP / Postal Code Mobile(Required)Home PhoneWorkEmail(Required) Enter Email Confirm Email Previous Martial Arts Experience(Required)Emergency Contacts1.Name(Required) First Last Home Phone(Required)Mobile(Required)Relationship to Student(Required)2.Name First Last Home PhoneMobileRelationship to StudentMedical Details (Both instructors are trained in first aid)Injuries (Current/Past)(Required)Allergies(Required)*Medical Conditions(Required)**Medications Needed(Required)Other Health Concerns/Issues(Required)*Feel free to talk to instructors about conditions/concerns in greater detail if needed.**Please provide instructors with any action plans required for yourself/your child/ren.Ambulance Membership(Required) Yes NoMembership No.(Required)Do you give us permission to call an ambulance if required?(Required) Yes NoRelease and IndemnityThis agreement is between...(students name)(Required);Kenshin Karate Pty Ltd; its instructors; its volunteers; its independent contractors; all other employees; and affiliated members hereinafter collectively referred to as KENSHIN. In consideration for enrollment in KENSHIN programs, the above named student (or parent/guardian of above named student) makes the following statements and promises: 1. I acknowledge before signing this agreement, that many of the techniques taught in KENSHIN programs are intended strictly for physical fitness and sometimes self-defense purposes, and that these techniques are not to be used in a negative or aggressive manner against any person or property. I understand that I may be expelled at any time from participation in a program or event if the instructors learn that I have used these techniques in a negative or aggressive manner against anyone or anything. 2. I agree that this agreement shall be binding upon my heirs, next of kin, representatives and assigns and that they: (a) will not make a claim against KENSHIN for any injury, death or property damage resulting directly or indirectly from my participation in a KENSHIN program or event; and (b) will release and discharge KENSHIN from any claims or demands arising from injury, death or property damage caused by my participation in a KENSHIN program or event. 3. I am aware that participation in KENSHIN programs can involve strenuous physical activity and when in question agree to consult with my primary health care practitioner before engaging in such challenging fitness activities. 4. I understand that training will include punching and kicking contact against training equipment. I understand that I have the option of participating in contact drills with other students and instructors. With this knowledge, I voluntarily assume the full risk and responsibility for any and all psychological and/or bodily injury, death or property damage arising from actions or conduct of KENSHIN or during a KENSHIN event. 5. I promise to defend, indemnify and hold harmless KENSHIN from any claims made by third parties alleging injury or damage resulting from my conduct and activities while on KENSHIN premises or during a SEISHIN sponsored event, from my conduct as a KENSHIN student and from any techniques learned in a KENSHIN program. 6. I agree that there have been no oral representations, statements or inducements made apart from this written agreement 7. In the event of injury, condition or death that surpasses the capabilities of KENSHIN instructors, I hereby give permission to obtain qualified emergency medical assistance and do not hold KENSHIN liable for such occurrence. 8. I have carefully read this agreement and fully understand its contents. I am aware that this agreement is a release or liability and responsibility between myself and KENSHIN. I voluntarily agree to each of the terms and provisions thereof and sign this agreement on my own free will.Is the attendee under 18 years of age?(Required) Yes NoSignature(Required)Signature of Parent/Guardian(Required)Name Printed(Required) First Last Date(Required) Day Month Year Does an immediate family member currently attend classes at Kenshin Karate?(Required) Yes NoCredit Card
