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Atienza Kali Participant Waiver: Valid for one year

The undersigned hereby acknowledges and understands that all activities related to martial arts and martial art training generally is dangerous.
The undersigned hereby acknowledges and understands that Atienza Kali/Atienza Kali, LLC cannot and does not insure against all possible injuries or losses connected to or arising from martial arts related activities, including, but not limited to, Atienza Kali training. The undersigned hereby acknowledges and understands that injuries can occur due to their own negligence, the unintentional acts of others or through no fault of any individual or group of individuals, due to the inherently dangerous nature of martial arts training.
In consideration for the undersigned participating in a seminar, clinic and/or private class from Atienza Kali/Atienza Eskrima (hereinafter, “A.K/AE.”) and/or Alden Atienza, Allain Atienza, Darryl Atienza, in addition to other good and valuable consideration, the receipt and adequacy of which is hereby acknowledged, the undersigned and his/her heirs, executors, administrators, immediate family members, personal representatives, successors and assigns, hereby release and hold harmless Atienza Kali LLC, A.K./AE, Alden Atienza, Allain Atienza, Darryl Atienza, any immediate family members, instructors and/or students, its associates, members, agents, officers, directors, servants and/or employees, of and from any and all liability, claims, rights, demands, actions and causes of action whatsoever, arising out of or relating to any loss, damage, injury, or death that may be sustained by the undersigned, or any loss or damage that may be sustained to any property of the undersigned, which occurs at the time of such seminar/private class or which may develop or be discovered in the future whatsoever.


The undersigned further acknowledges and agrees that, due to the specialty nature of the martial arts instruction provided by A.K./AE and/or Alden Atienza, Allain Atienza, Darryl Atienza, he/she will NOT instruct, teach, reproduce, or otherwise disclose, in any manner whatsoever, to any third party, any of the martial arts instruction provided by Atienza Kali LLC, A.K./AE and/or Alden Atienza, Allain Atienza, Darryl Atienza.


The undersigned understands that the instruction provided might subject the undersigned to physical, psychological, and/or mental stressors and certifies that he/she is of sufficient mental and physical condition to participate without risk of harm to the undersigned.
The undersigned further agrees that he/she has notified Atienza Kali LLC, A.K./AE and/or Alden Atienza, Allain Atienza, Darryl Atienza about any physical, psychological and/or mental conditions that may potentially make any or all activities unsafe for the undersigned to perform and has consulted a physician and/or other medical professional about such condition, if it exists to ensure there is no risk to the undersigned.


The undersigned voluntarily assumes any and all risk of loss, damage, injury, including death, which may occur to oneself or others as a result of use or training of any skills, techniques or systems of analysis, which is taught in this program.


The undersigned understands that Atienza Kali LLC, A.K./AE and/or Alden Atienza, Allain Atienza, Darryl Atienza, its’ assigns, agents, family members or designees may take photographs, films or otherwise capture electronic images at the event which the undersigned is hereby attending. In addition, such images may be captured by Atienza Kali, its assigns, agents, family members or designees during any activity pre or post-event but which is related to the event. In consideration for permission to participate in this event, the undersigned waives any and all rights to these images and give Atienza Kali/Atienza Eskrima, its assigns, agents or designees permission to use said images for any purpose, whether commercial or otherwise, without restriction.


By signing this Release and Hold Harmless agreement, the undersigned waives to the extent permitted by the laws of the United States and the State of Pennsylvania, any claim in law or in equity, which the undersigned, or others on his/her behalf may have against Atienza Kali/ Atienza Kali LLC, their immediate family members, principals, instructors, students, members, servants, agents & assigns and agrees to indemnify Atienza Kali/Atienza Kali LLC, their immediate family members, principals, instructors, students, members, servants, agents and assigns for any and all costs or legal expense incurred in defending any claims made by the undersigned or others on his/her behalf, as well as for any claims brought against me or my representative by others arising from my participation in this training program.
The undersigned hereby acknowledges that this Release and Hold Harmless agreement is a binding legal instrument. That in signing it, he/she is relinquishing specific
rights and privileges under the laws of the United States and that he/she has executed this document knowingly and voluntarily.
The undersigned hereby acknowledges and agrees that any event and or claim which arises from his/her participation in this training program or the execution of this document, itself, will be governed by the laws of Pennsylvania and should any portion of this instrument be deemed by a Pennsylvania court to be invalid and/or unenforceable, the remaining terms shall continue with full force and effect.

April 23, 2019

First Participant's Name

First Name*

Last Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First 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*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Any Known Physical Injuries and/or Conditions?
Do you have any known physical injuries and/or conditions?*
No
Yes

If you clicked Yes, please list.
Event

Please list event you are participating/attending *
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.
Parent or Guardian's Name

First 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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