Kids Ages 5-6 Program- Aka To Kuro Martial Arts School LLC Student Application

Aka To Kuro Martial Arts School LLC

Teaching Shodin Ji Do Karate

If you are not the child's parent or guardian please do not proceed with application.

Student Name*

First NameLast Name

Student Nickname: (If they have one)

Student Date of Birth*

If you are signing up multiple siblings, use this section:

First Name   Last Name   Date of Birth

First Name   Last Name   Date of Birth

First Name   Last Name   Date of Birth

First Name   Last Name   Date of Birth

Current address:*

City:

State:

Parent Name*

First NameLast Name

Parent Phone Number:*

Parent E- mail Address:*

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Relationship to student:*

Spouse Name

First NameLast Name

Spouse Email Address

example@example.com

Spouse Phone Number

Please enter a valid phone number.

Media Release Form and Permission to Use Photography

Name of School: Aka To Kuro Martial Arts School LLC

Name of Style: Shodin Ji Do Karate

Subject: Classes, events, activities and programs specific to Aka To Kuro Martial Arts School LLC

Location: Aka To Kuro Martial Arts School LLC, at 1011 E Bender Hobbs, NM, and/or any deemed and specified locations, events, classes, programs or activity.

I grant to Instructor Esther C Bratcher (Senior Instructor and owner) of Aka To Kuro Martial Arts School LLC, its representatives, assistant instructors, employees, volunteers and designees the right to take photographs of me and my child/ren in connection with the above-identified subject. I authorize Aka To Kuro Martial Arts School LLC, its assignees and transferees to copyright, use and publish the same in print and/or electronically and/or for social media sites.

I agree that Aka To Kuro Martial Arts School LLC, may use such photographs of me and my child/ren with or without my name and for any lawful purpose, including, for example: such purposes as publicity, illustration, advertising, internet, and website content.

Do you approve of our Media Release Policy. *

Prayer and Pledge Policy

Prior to each class and/or event, we will be saying a prayer and The Pledge of Allegiance.

The words of the prayer are below:

"Dear God,

Thank you for my faith, family and freedom.

Allow me the confidence and resilience to succeed.

Guide me to make good choices and be the best version of myself.

Amen"

If you do not agree with the prayer or pledge simply arrive 5 minutes after class/events have started. Start times are indicated on schedules and flyers.

Medical Treatment Authorization Form

This form grants temporary authority to a designated adult to provide and arrange for medical care for a minor in the event of an emergency where the minor is not accompanied by either parents or legal guardians, and in the event it may not be feasible or practical to contact them.

Physician's Location of practice and contact information:

Physician's Name (if applicable)

First NameLast Name

Physician's Phone Number (if applicable)

Please enter a valid phone number.

Name of Hospital Clinic and/or Doctor

Allergies to Medications: (If NONE please type "NONE") If you have multiple kids please specify.*

Allergies (Other): Please note all conditions for which the child is currently receiving treatment. If you have multiple kids please specify.

Let us know of any behaviors that will help teach our new student karate. If you have multiple kids, please specify.

AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)

I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for any adult instructor of Aka To Kuro Martial Arts school (hereafter "Designated Adult") to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Designated Adult to summon any and all professional emergency personnel to attend, transport, and treat the minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care. It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Designated Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel.

WAIVER/RELEASE FOR COMMUNICABLE DISEASES INCLUDING COVID-19 ASSUMPTION OF RISK / WAIVER OF LIABILITY / INDEMNIFICATION AGREEMENT

In consideration of being allowed to participate in Aka To Kuro Martial Arts School LLC and related events and activities, the undersigned acknowledges, appreciates, and agrees that:

1. Participation includes possible exposure to and illness from infectious diseases including but not limited to MRSA, influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; and,

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,

3. I willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against infectious diseases. If, however, I observe and any unusual or significant hazard during my presence or participation, I will remove myself/child from participation and bring such to the attention to the nearest adult instructor/adult in charge, immediately.

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Aka To Kuro Martial Arts School LLC, their volunteers, board members, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the classes, events or activities (“RELEASEES”), WITH RESPECT TO ANY AND ALL ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IF FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT

Aka To Kuro Martial Arts School LLC

Teaching Shodin Ji Do Karate

Release and Waiver of Liability and Indemnity Agreement

(Read Carefully Before Signing) In consideration of being permitted to participate in any way in the Aka To Kuro Martial Arts School LLC program indicated and/or being permitted the parent(s) and/or legal guardian(s) of the minor participant named below agree:

The parent(s) and/or legal guardian(s) Arts activity or event, he or she can be permitted to inspect the facilities and equipment to be used and if he or she believes anything is unsafe, the participant should immediately advise the officials of such condition and refuse to participate. I understand and agree that, if at any time, I feel anything to be UNSAFE; I/my child/ren will immediately take all precautions to avoid the unsafe area and REFUSE TO PARTICIPATE further.

1. I/We fully understand and acknowledge that:

a. There are risks and dangers associated with participation in Martial Arts events and Activities which could result in bodily injury partially and/or totally disability, paralysis and death.

b.The social and economic losses and/or damages, which could result from these risks and dangers described above, could be severe.

c. These risks and dangers may be cause by the action, inaction or negligence of the participant or the action, inaction or negligence, of others, including, but not limited to, the Released names below.

d.There may be other risks not known to us or are not reasonable foreseeable at this time.

2. I/WE accept and assume such risks and responsibility for the losses and/or damages following such injury, disability, paralysis or death, however caused and whether caused in whole or in part by the negligence of the Released names below.

3. I/We HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Aka To Kuro Martial Arts Scool LLC including its committee members, employees and any administrators, any Martial Arts Instructors, including but not limited to Owner Esther C. Bratcher, other Martial Arts Instructors, Martial Arts Assistant instructors, those associated with Shodin Ji Do Karate, managers, promotors, leases of premises used to conduct the Martial Arts event or program, premises and event locations, inspectors, underwriters, consultants and others who give recommendations, directions or instructions to engage in risk evaluation or loss control activities regarding the martial arts facility or events held at such facility and each of them, their directors, officers, agents, employees, all for the purpose herein referred to as "Releasee" From all liability to the undersigned, my/our personal representatives, assigns, executors, heirs, and next to kin for any and all claims, demands, losses or damages and any claims or demands therefore on account of any injury, including but not limited to the death of the participant or damage to property, arising out of or relating to the event(s) caused alleged to be caused on whole or in part by the negligence of the Releasee or otherwise.

4. I /We HEREBY acknowledge that THE ACTIVITIES OF THE EVENT(S) ARE VERY DANGEROUS and involve the risk of serious injury and/or death and/or property damage. Each of the undersigned also expressly acknowledge that INJURIES RECEIVED MAY BE COMPOUNDED OR INCREASED BY NEGLIGENCE RESCUE OPERATIONS OR PROCEDURES OF THE RELEASEES.

5.EACH OF THE UNDERSIGNED further expressly agrees that the forgoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as is permitted by the law of the province or state in which the event is conducted and that if any portion is held invalid, it is agreed that the balance shall, notwithstanding continue in full legal force and effect.

On behalf of the participant and individually, the undersigned partners(s) and/or legal guardian(s) for the minor participant executes this Waiver and Release. If, despite the release, the participant makes a claim against any of the Releasees, the parents(s) and/or legal guardians(s) will reimburse the Releasee for any money which they have paid to the participant, or on his behalf, and hold them harmless.

I have read this release and waiver of liability, assumption of risk and indemnity agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and have signed it freely and voluntarily without any inducement, assurance, or guarantee being made to me and intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

Aka To Kuro Martial Arts School LLC 1011 E BENDER BLVD

Teaching Shodin Ji Do Karate

Payment Withdraw:

My payment (plus tax) will be automatically withdrawn on the chosen date (choose the 1st or 5th) of every month.

Please Choose One *

Tuition Fees:

2 classes a week is $129.99 a month per student. This cost includes a belt, and testing fees.

I agree to pay the agreed apon amount on my scheduled due date.

This amount will be automatically withdrawn from the credit/debit card I provide.

I understand no refunds will be given after a charge has been processed.

Service Disclosure:

Disrespectful behavior from any student and/or their parent/s will not be tolerated. We respectfully reserve the right to refuse service to any student, at any time in their martial arts career.

Printed Name of Parent*

Signature (if minor) of Parent or Legal Guardian*

Clear

Printed Name of Second Parent (Optional)

Signature (if minor) of Second Parent or Legal Guardian (Optional)

Clear

By Clicking "SUBMIT" I understand and agree to all Aka To Kuro Martial Art School LLC's "Student Application". If I have any questions or do not understand, I will ask prior to submitting this application.

STUDENT APPLICATION

PARENT INFORMATION IF STUDENT IS UNDERAGE (18)

EMERGENCY CONTACT

SPOUSE INFORMATION IF APPLICABLE

Prayer and Pledge Policy

Tuition Cost, Auto Payment Policy and Agreement