Hokushin Judo Workout

Name*

First NameLast Name

E-mail*

Club*

Club NameLocation

Birth Date (ages 5+)*

YearMonthDay

Parent or Legal Guardian

First NameLast Name

Phone Number:*

Area CodePhone Number

Emergency Contact*

First NameLast Name

Emergency Contact Phone Number*

Area CodePhone Number

Address:*

Street Address

City

State

Zip Code

What is your Judo rank*

Where did you hear about the clinic?

Sessions attending

Qty 1 Session: 12 noon - 3:00pm

Usage of photos and video*

I understand that occasionally, photos and videos from the Hokushin Judo Workout will be used in promotional material for Hokushin Judo, LLC, New Wave Jiu Jitsu, Six Blades Jiu Jitsu, and Indiana Judo. I agree to allow my image or my child's image to be used for this purpose and that I will not be compensated. I also understand that once a promotional item has been produced, it is not possible to remove my image or my child's image from the production.

Recognize and understand that Judo is a physical contact activity and that my participation might result in serious injury, including permanent disability or death, and severe social and economic loss.
Recognize and understand that such risk may be due to not only my own actions, but also the action, inaction or negligence of others.
Recognize that there may be other risks that are not known to me or to others or not reasonably foreseeable at this time.
Agree to inspect the facilities, equipment and pairings prior to participation. I will immediately inform the event organizer if I believe that anything is unsafe or beyond my capability and refuse to participate.
Assume all of the foregoing risks and accept personal responsibility for any damages that may result from injury, permanent disability or death.
Enter the Hokushin Judo Workout, Judo training, randori and/or competition entirely of my own free will and understand the importance of following the rules of training and competition.
I certify that I am in good physical condition, and have no disease, injury or other condition that would impair my performance or physical and mental well-being during the Hokushin Judo Workout. If I have any injuries or illnesses that could affect my ability to participate, I will notify the event organizer, and discuss the appropriateness of participating in the Hokushin Judo Workout with my or my child's doctor.
Grant permission in case of injury to have a doctor, nurse, athletic training or other emergency medical personnel provide me or my child with medical assistance or treatment for such injury. The cost of any treatment or hospitalization arising from injury during training or play shall not under any circumstance be paid by Hokushin Judo, LLC., New Wave Jiu Jitsu, Indiana Judo, Inc., Six Blades Jiu Jitsu, Mario Camacho (organizer), and Tahir Sharif (property owner), its affiliated organizations and governing bodies, their officers, instructors and personnel, other members of the organizations, participants, supervisors, coaches, sponsoring organizations or their agents.
Release, waive, discharge and covenant not to sue, Hokushin Judo, LLC., New Wave Jiu Jitsu, Six Blades Jiu Jitsu, Indiana Judo, Inc., Mario Camacho (organizer), and Tahir Sharif (property owner), its affiliated organizations and governing bodies, their officers, instructors and personnel, other members of the organizations, participants, supervisors, coaches, sponsoring organizations or their agents, and if applicable, owners and leasers of the premises from any and all liability to the undersigned, his or her heirs and next of kin for any and all claims, demands, losses and damages which may be sustained and suffered on account of injury, including death or damage to property, caused or alleged to be caused in whole or in part by the negligence of the realeasees or otherwise.

Waiver and Liability Agreement Acceptance*

I have read, understood, and accept the disclaimer and liability waiver and sign it of my own free will

Signature of Participant or Legal Guardian*

Workout at Hokushin Judo - Waiver

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Disclaimer and Waiver of Liability