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Naka Ima Waiver Form

The undersigned understands that the martial arts offered at Naka Ima Aikikai, including aikido and karate, are contact martial arts involving strenuous exercise and weapons training. The undersigned further acknowledges that Naka Ima Aikikai Inc. (the Dojo) does not carry insurance and provides no guarantee of any kind against injuries to any of its students. In consideration of acceptance as a student of Naka Ima Aikikai Inc., receipt of instruction, the use of the Dojo facilities and equipment (collectively Dojo Activities), the undersigned hereby irrevocably declares that the undersigned personally assumes all responsibility concerning any injury that the undersigned may incur or be caused to the undersigned while on the Dojo premises

The undersigned covenants and agrees to indemnify and save harmless the Dojo from and against any loss or damage suffered by the undersigned on behalf of (where applicable) the undersigned, his/her heirs, executors, administrators and assigns, hereby release, acquit, remise and forever discharge the Dojo, each of its subsidiaries, associated and/or affiliated companies and any of its successors, assigns, affiliates, divisions, predecessors, agents, servants, employees, officers, directors, instructors, students, representatives and each of them (collectively the "Releasees") of and from any and all manner of actions, causes of action, proceedings suits, debts, dues, duties, accounts, bonds, covenants, contracts, claims and demands of every kind, known or unknown, whatsoever which against the said Releasees the undersigned now has, ever had or hereinafter can, shall or may have for or by reason of any cause, matter or thing whatsoever and, without limiting the generality of the foregoing, arising out of or in any way related to the Dojo Activities.

The undersigned has read and accepts the foregoing.

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Please provide any health issues (if any) that our instructors should be aware of
Which Naka Ima class(es) are you participating in?
Trial Class
Aikido
Karate
Seminar
Other
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Please provide any health issues (if any) that our instructors should be aware of
Which Naka Ima class(es) are you participating in?
Trial Class
Aikido
Karate
Seminar
Other
Third Participant's Name

First Name*

Middle Name

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

Please provide any health issues (if any) that our instructors should be aware of
Which Naka Ima class(es) are you participating in?
Trial Class
Aikido
Karate
Seminar
Other
Fourth Participant's Name

First Name*

Middle Name

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

Please provide any health issues (if any) that our instructors should be aware of
Which Naka Ima class(es) are you participating in?
Trial Class
Aikido
Karate
Seminar
Other
Fifth Participant's Name

First Name*

Middle Name

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

Please provide any health issues (if any) that our instructors should be aware of
Which Naka Ima class(es) are you participating in?
Trial Class
Aikido
Karate
Seminar
Other
Sixth Participant's Name

First Name*

Middle Name

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

Please provide any health issues (if any) that our instructors should be aware of
Which Naka Ima class(es) are you participating in?
Trial Class
Aikido
Karate
Seminar
Other
Seventh Participant's Name

First Name*

Middle Name

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

Please provide any health issues (if any) that our instructors should be aware of
Which Naka Ima class(es) are you participating in?
Trial Class
Aikido
Karate
Seminar
Other
Eighth Participant's Name

First Name*

Middle Name

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

Please provide any health issues (if any) that our instructors should be aware of
Which Naka Ima class(es) are you participating in?
Trial Class
Aikido
Karate
Seminar
Other
Ninth Participant's Name

First Name*

Middle Name

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

Please provide any health issues (if any) that our instructors should be aware of
Which Naka Ima class(es) are you participating in?
Trial Class
Aikido
Karate
Seminar
Other
Tenth Participant's Name

First Name*

Middle Name

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

Please provide any health issues (if any) that our instructors should be aware of
Which Naka Ima class(es) are you participating in?
Trial Class
Aikido
Karate
Seminar
Other
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
Check to receive schedule changes, events and news updates by email.
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Photo/Video Release
I hereby give permission for images of me and my child/children (if applicable), captured during regular and special aikido activities through video, photo and digital camera, to be used solely for the purposes of Naka Ima Aikikai promotional material and publications, and waive any rights of compensation or ownership thereto.*
No
Yes
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 Information

Please provide any health issues (if any) that our instructors should be aware of
Which Naka Ima class(es) are you participating in?
Trial Class
Aikido
Karate
Seminar
Other
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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