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Black Belt Testing

I hereby release John Marshall, Family Karate Centres and all person associated with these scheduled black belt endurance workouts in any capacity, from any liability due to injuries etc. , That I may incur as a result of my attendance and or participation in the above mention activity.

I clearly understand that some aspects of this sport involve bodily contact.  I have been made aware, understand and agree to abide by the guidelines associated with Family Karate rules and regulations and assume all responsibility and any associated liability or infringement of such guidelines.  Additionally, I am fully aware of my personal medical condition and hereby certify that I am mentally and physically fit to participate in said activity.

Student hereby represents that he/she is physically fit, and does not suffer from any disease, illness, or disability including muscular, bone, neck or spinal ailments other than those listed above, to take prescribed course of instruction and that he/she has had an opportunity to observe and/or participate in the above described art of self-defense prior to signing this agreement

Student understands further that strict observation of the rules and regulations relative to training include the use of protective equipment required by FAMILY KARATE LTD.  This equipment is to minimize the possibility of accident or injury, however, FAMILY KARATE LTD. does not warrant the protective equipment.  FAMILY KARATE LTD. reserves the right to refuse return of used uniforms and equipment.  Student understands that during the course of instruction, employees of FAMILY KARATE LTD. and/or other students or authorized persons will be engaged in a course of conduct requiring physical contact, he/she gives full consent to such contact as it is required by the training.

Today's Date: October 21, 2019

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

List any medical information please. *

Black Belt Testing Start Date *
First Participant's Signature*
Second Participant's Name

First Name*

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

List any medical information please. *

Black Belt Testing Start Date *
Third Participant's Name

First Name*

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

List any medical information please. *

Black Belt Testing Start Date *
Fourth Participant's Name

First Name*

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

List any medical information please. *

Black Belt Testing Start Date *
Fifth Participant's Name

First Name*

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

List any medical information please. *

Black Belt Testing Start Date *
Sixth Participant's Name

First Name*

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

List any medical information please. *

Black Belt Testing Start Date *
Seventh Participant's Name

First Name*

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

List any medical information please. *

Black Belt Testing Start Date *
Eighth Participant's Name

First Name*

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

List any medical information please. *

Black Belt Testing Start Date *
Ninth Participant's Name

First Name*

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

List any medical information please. *

Black Belt Testing Start Date *
Tenth Participant's Name

First Name*

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

List any medical information please. *

Black Belt Testing Start Date *
Parent or Guardian's Email Address

Email*

Confirm Email*
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Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
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*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

List any medical information please. *

Black Belt Testing Start Date *
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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