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PACIFIC RENBUKAI KARATE LLC

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, Pacific Renbukai Karate Do, Pacific Renbukai Karate, of Renbukai and or Pacific Renbukai Limited OR named sensei")

 

Express assumption of risk: I, the undersigned, am aware that there are significant risks involved in all aspects of physical training. These risks include, but are not limited to: falls which can result in serious injury or death, injury or death due to negligence on the part of myself, my training partner, or other people around me, injury or death due to improper use or failure of equipment. 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 activity or class while under direction of  PACIFIC RENBUKAI KARATE LLC. I, the undersigned acknowledge that I have no physical impairments or illnesses that will endanger myself or others. 

 


 

Release: In consideration of the above mentioned risks and hazards and in consideration of the fact that Iam willingly and voluntarily participating in the activities available at PACIFIC RENBUKAI KARATE LLC.  I, the undersigned hereby release PACIFIC RENBUKAI KARATE LLC OR ANY 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  to administer first aid deemed necessary, and in case of serious illness or injury, I give permission to call for medical and or surgical care for the child and to transport the child to a medical facility deemed necessary for the well being of the child. 

 


 

Indemnification: The participant recognizes that there is risk involved in the types of activities offered by  PACIFIC RENBUKAI KARATE LLC. 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. 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, 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. 

 


 

I have read and understood the foregoing assumption of risk, and release of liability and I understand that by signing it obligates me toindemnify 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 athletic, social, or instructional activities.

 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's 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.
Richmond After school Option
After school Richmond and Macadam Ave.-No extra fee
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 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 location and duration. Thank You.
Specify Class-for multiple location *
Winter 2024- Special 2 months After school- (January-February end) every Wednesday 2:15-3:30PM at Richmond Elementary
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 Only
Fall- Sept begin-Nov end -limited enrollment at after school location- See calendar and email verification for start end or school mandated closures due to event and/or emergencies and/or inclement weather.
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*
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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