September 14, 2024 - Colton Brown Judo Clinic Registration
Please complete the form below to sign up
Name
*
First Name
Last Name
E-mail
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Club
*
Club Name
Location
Birth Date (ages 5+)
*
Please select a year
2024
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Year
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Month
Please select a day
1
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Day
Parent or Legal Guardian
First Name
Last Name
Phone Number:
*
-
Area Code
Phone Number
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Address:
*
Street Address
City
State
Please Select
Alabama
Alaska
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District of Columbia
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Vermont
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State
Zip Code
Is your club an Indiana Judo Club member?
*
Yes
No
What is your Judo rank
*
White
Yellow
Orange
Green
Blue
Purple
Brown
Black
What session(s) will you attend
*
Session 1: 11:30am - 1:00pm (Ages 5-18)
Session 2: 1:30pm - 3:30pm (Adults and Juniors Orange belt and above)
Session 3: 4:00pm - 6:00pm - Competition scenarios and Randori (Adults and Juniors Orange belt and above)
Attending multiple sessions
Where did you hear about the clinic?
A friend, teammate or coach
Online search (Google, Bing, Yahoo)
Indiana Judo Website
Facebook Indiana Judo
Flyer at tournament
Other
Payment
You can pay the day of the event (we accept cash or checks). Make checks payable to Mario Camacho (Please indicate number of Sessions attending below.)
Sessions attending - Indiana Judo (IJI) Club Members
Qty 1 Session: $25
Qty 2 Sessions: $40
Qty 3 Sessions: $50
Sessions attending - Out of State and Non-IJI Club Members
Qty 1 Session: $40
Qty 2 Sessions: $60
Qty 3 Sessions: $70
Privacy Policy
Usage of photos and video
*
I understand that occasionally, photos and videos from the Colton Brown Judo Clinic will be used in promotional material for Colton Brown, Hokushin Judo, LLC, Six Blades Jiu Jitsu, New Wave 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.
Disclaimer and Waiver of Liability
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 Colton Brown Judo Clinic, 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 Colton Brown Judo Clinic. 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 Colton Brown Judo Clinic 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., Six Blades Jiu Jitsu, New Wave Jiu Jitsu, Indiana Judo, Inc., Mario Camacho (organizer), Tahir Sharif (property owner) and Colton Brown (clinician), 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., Six Blades Jiu Jitsu, New Wave Jiu Jitsu, Indiana Judo, Inc., Mario Camacho (organizer), Tahir Sharif (property owner) and Colton Brown (clinician), 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
*
Submit Registration
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