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PACIFIC RENBUKAI KARATE LLC, Pacific Renbukai Karate Dojo Institute

Registration for Enrollment

Release of Liability, Waiver of Claims, Assumption of Risk and Indemnity Agreement

 

BY SIGNING THIS DOCUMENT YOU WILL WAIVE CERTAIN and ALL LEGAL RIGHTS. INCLUDING THE RIGHT TO SUE.

 

 PACIFIC RENBUKAI KARATE LLC. owners, volunteers, directors, officers, employees, trainers, instructors, agents, officials, independent contractors, representatives, successors and assigns (hereinafter referred to as "PACIFIC RENBUKAI KARATE LLC, Pacific Renbukai Dojo Institute, Pacific Renbukai Karate Do, Pacific Renbukai Karate, of Renbukai and or Pacific Renbukai Limited OR named "sensei" or "senpai")

 

Express Assumption of Risk: I, the undersigned, am aware that there are significant risks involved in all aspects of physical training by participating in a karate class. These risks include, but are not limited to: falls, sweeps or take downs which can result in serious injury or death, injury or death due to negligence on the part of my own actions, my training partner actions, or other people around me actions, injury or death due to improper use or failure of safety equipment and my failure to adhere to safety measures during training and/or my own or other's physical movements of punches, kicks, or hand strikes that result in a physical injury and to any participant due to failure to follow class instructor's directions or my own physical limitations. I am aware that any of these above mentioned risks may result in serious injury or death to myself and or my partner(s). I willingly assume full responsibility for the risks that I am exposing myself to and accept full responsibility for any injury or death that may result from participation in any karate or self defense activity while under direction or practice place of PACIFIC RENBUKAI KARATE LLC, Pacific Renbukai Karate Dojo Institute. I, the undersigned acknowledge that I have no physical impairments or illnesses, conditions (including a mental and/or a physical diagnosis) that could endanger myself or others. I will also agree to disclose any and all medications that I am prescribed.Illegal use narcotics and or alcohol intoxication is prohibited while participating in karate do instruction.



Express Agreement to Permit Limited Physical Adjustments by touch from Instructor : I, the undersigned, am aware that traditional Japanese karate instruction involves movement correction to adhere to the posture, depth of stances, hand and foot positions that are defined in a Japan Karate Federation manuals published yearly in Japan. I agree that Movement correction is essential to learning a traditional art such as karate do and ensuring participant safety and curriculum adherence. Touch Corrections are accompanied by verbal corrections that are only specific to and limited to the student's: posture (head,neck, shoulders and back), arms:(fist, open hand, forearm and pulling hand), and legs: (knees,and feet) . I understand that correct self controlled movements are the goals of the study of karate do and the study is always aided by instructor guidance.


Agreement to Follow Training Behavior and Safety Rules: I, The undersigned, am aware that class behavior rules are designed for safety primarily. Verbal harassment (name calling, stalking, negative comments on or about sexual orientation)in person or online or Physical harassment (including but not limited to inappropriate or continued unwarranted advances) towards any student from another student are grounds for expulsion without tuition reimbursement. Students are not permitted before, during or after classes to: run, spar, push, shove,take down, sweep, hit or kick , pull hair, poke or joint lock or perform any choke holds to any other student outside of the direct instruction of an instructor during class time in the specified training areas. Dressing rooms, hall ways, waiting rooms, and entry areas are not training areas. training areas are defined as: tatami floor, open floor and gym areas. If ,for any reason a participant in a class uses any learned technique in and offensive(not defensive manner) in a school or public setting this can and will be a reason for an immediate full expulsion and release from any associated liabilities without any tuition reimbursement. I also agree that Instructor's and/or Sensei's have the discretion to expel any student who violates any or all of the above violations.


Dressing rooms are limited to adults only times (6:20-7:30PM nightly) and children/teen (under 18 years old) 4:00-6:20PM Daily.Bathrooms are available for clothes changing. (off site and schools) Children area specified to change in tents when bathroom areas are not accessible. Tents are designed for one person at a time. No Adult can be in a changing room or bathroom with a minor unless they are a parent and/or guardian. If your student is in class transition time where both children and adults can be present the adult must utilize the bathroom for changing purposes.


Requirement of wearing safety protection equipment to ensure safety: I, The undersigned, am aware that safety equipment is required for all (under 18) contact sparring. This includes but is not limited to: groin cup (men,boys), hand protection, shin and foot protection, mouth guards for ANY SPARRING activity for children. Sparring is not permitted at on site After school locations. Demonstrations of sparring is permitted on site school with Orange belt 3 years experience only under specific technical prearrangement. I understand that am required to purchase sparring safety equipment after 1st belt advancement( yellow).

Adults and ages 16+ not utilizing all safety equipment assume all risk and release Pacific Renbukai of any assumed liabilities.


I agree to grant permission to have any student's photographs reproduced online to social media for advertising purposes.



 

Release: In consideration of the above mentioned risks and hazards and in consideration of the fact that I am willingly and voluntarily participating in the karate do activities available at PACIFIC RENBUKAI KARATE LLC. I, the undersigned hereby release PACIFIC RENBUKAI KARATE LLC OR ANY Pacific Renbukai Karate Dojo Institute ,Renbukai their principals, agents, employees, and volunteers from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my participation in this activity, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties.

 


This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or transferees. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full legal force and effect.If I am signing on behalf of a minor child, I also give full permission for any person connected with PACIFIC RENBUKAI KARATE LLC and or Pacific Renbukai Karate Dojo Institute to administer first aid deemed necessary, and in case of serious illness or injury, I give permission to call (911) for any medical and or surgical care for a minor and any adult  and I give permission to transport the minor and or adult to a medical facility if deemed necessary and emergency care is not immediately available . 

 


 

Indemnification: The participant recognizes that there is risk involved in the types of activities offered by PACIFIC RENBUKAI KARATE LLC, Pacific Renbukai Karate Dojo Institute. Therefore the participant accepts financial responsibility for any injury that the participant may cause either to him/herself or to any other participant due to his/her negligence or failure to adhere to safety measures directed by instructors. Should the above mentioned parties, or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to reimburse them for such fees and costs. I further agree to indemnify and hold harmless PACIFIC RENBUKAI KARATE LLC and Pacific Renbukai Karate Dojo Institute, their principals, agents, employees, and volunteers from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in activities offered by PACIFIC RENBUKAI KARATE LLC and or Pacific Renbukai Karate Dojo Institute. 

 


 

I have read and understood the foregoing assumption of risk, and release of liability and I understand that by signing it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligent or intentional act or omission. I understand that by signing this form I am waiving valuable legal rights.

 

This agreement must be completed in full, initialed where indicated, dated, signed and witnessed prior to participating in any PACIFIC RENBUKAI KARATE LLC and/or Pacific Renbukai Karate Dojo Institute's athletic, social, or instructional activities.

 

First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address
Email*
Confirm Email*
Class Registration locations
Please Specify Location of classes that your student will attend.*
Student will attend classes at Macadam Ave. location Only. (TUE/TH)
Full Membership at: Hawthorne Blvd DOJO (MON), Macadam Ave DOJO (TU/TH)with DOJO institute class After school Onsite at Richmond Elementary while school is in Service (WE)-up to 4 classes per week.
Intensive-Instructor approval- Afternoon/Evening up to 2 hours daily (TUE/THUR) includes all locations and times.
Student will attend classes at 3942 Hawthorne Blvd Dojo
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
2nd Emergency Contact (must be different from Primary)
Name:
Phone Number:
Email:
Any Pre-existing Medical (including physical and mental diagnonsis)Conditions:
Condition
Is there any RX prescription that the student will need to administer (self)if participant has onset during class?
Location and Duration:
Please SPECIFY Class locations: Hawthorne Blvd., Macadam Ave. or After school Onsite- Institute (Richmond) or Both-After School Onsite and/or Macadam Ave.
Specify Class Semester -for multiple location (please notify absence by email. Pacrenbogukarate@gmail.com) Pick up Afterschool must be with in 15 min of class end.(Late p/u fee imposed after)*
Fall- Sept begin-Nov end -limited enrollment at after school location- See calendar and email verification, notices. Please note: school/district wide mandated closures due to event and/or emergencies and/or inclement weather will automatically cancel class. (No refunds for City/District closures)Make up classes at Macadam will occur.(see schedule)
Winter-Dec, Jan , Feb. See above for possible class cancellations.
Spring-March,April, May. See above for possible class cancellations.
Summer-June, July, August- Macadam and/or Hawthorne Only
Any Month Begin- ALL Locations-Enrollment Begins Immediately after form completion.See class schedule for classes. Ends after 3 month Anniversary date.-Age and Ability classes.
STRIKE BACK -Self Defense Seminar- Sunday Jan 28th 11 AM-3 PM with 1/2 hour break.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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