Black Belt Test Registration

Black Belt Test Registration

November 23, 2024 ~ 9:00 am-4:00 pm Port Coquitlam Training Centre ~ 1740 Broadway Unit 1, Port Coquitlam V3C 2M8
Student Information
First Name*
Last Name*
Test Date

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Gender*
Age on Test Date
Student Email*
example@example.com
Student Phone Number*
Please enter a valid phone number.
Preferred Title
Your name will be embroidered on your belt as:
16 Years old and over
Your name will be embroidered on your belt as:
Under 16 years old
Embroidered names are the Preferred Title (Mr., Mrs, Ms. Miss or Mx. if you are 16 years old or over), your First Initial and your last name. If you would like your name embroidered differently (for instance you go by your middle name instead of your first name), please enter it below as you would like it on your belt. We do not put full first names or nicknames on belts. All changes must be approved.
Please change my embroidered name to:
Training Centre
What degree will you be testing for?
Belt Size

Emergency Contact Information
Contact Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relationship to Student
Will this person be within the vicinity (within 5km) during the test (9am-4pm)?*

YesNo
Second Contact Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to Student
Will this person be within the vicinity (within 5km) during the test (9am-4pm)?

YesNo

Liability Waiver
Release and Waiver of Liability and Indemnity Agreement (READ CAREFULLY BEFORE SIGNING).

In consideration of being permitted to participate in any way in the activities offered by Excel Martial Arts (the "Martial Arts Activities") and/or being permitted to enter for any purpose any restricted area (herein defined as any area where in admittance to the general public is prohibited), I agree to the following:

1. Prior to participating in the Martial Arts Activities, I will inspect the facilities and equipment to be used and if I find anything is unsafe, I will immediately advise the officials of such condition and refuse to participate until the situation is rectified. If at any time, I feel anything to be UNSAFE; I will immediately take all precautions to avoid the unsafe area and REFUSE TO PARTICIPATE further.

2. I fully understand and acknowledge that:
1. There are risks associated with participation in the Martial Arts Activities, which could result in bodily injury, including partial or total disability, paralysis and death.
2. The social and economic losses and/or damages, which could result from these risks could be severe.
3. These risks may be caused by the action, inaction, or negligence of the participant or the action, inaction, or negligence of others, including, but not limited to, the Releasees named below.
4. There may be other risks not known to us or are not reasonably foreseeable at this time.
3. I accept and assume such risks and responsibility for the losses and/or damages following such bodily injury, disability, paralysis or death, however caused and whether caused in whole or in part by the negiligence of the Releasees named below.

4. I HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Excel Martial Arts, including its owners, directors, officers, employees, agents, contractors, and landlords of any premises used to conduct the Martial Arts Activities (herein referred to as "Releasees") from all liability to the undersigned, my personal representatives, assigns, executors, heirs, and next of kin for any and all claims, demands, losses or damages as a result of an injury arising out of participation in the Martial Arts Activities, including but not limited to the disability. paralysis, or death of the participant or damage to the property, caused or alleged to be caused in whole or in part by the negligence of the Releasees or otherwise.

5. I HEREBY acknowledge that the Martial Arts Activities are dangerous and involve the risk of serious injury and/or death and/or property damage. The undersigned also expressly acknowledges that injuries received may be compounded or increased by negligent rescues or care operations or procedures of the Releasees.

6. THE UNDERSIGNED further expressly agrees that the foregoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as is permitted by the law of the Province of British Columbia in which the event is conducted and that if any portion is held invalid, it is agreed that the balance shall, not withstanding, continue in the full legal force and effect.

7. If despite the release, the participant or their family, makes a claim against any of the Releasees, the participant or their family, will reimburse the Releasees for any money which they have paid to the participant, or on his or her behalf and hold them blameless.

8. I agree to participate in the Black Belt Test.

9. Excel Martial Arts or any party designated by Excel Martial Arts may photograph or film me while I attend the premises of any Excel Martial Arts Training Center and use any and all such photos, video footage and/or video streaming for promotion, sales, publicity, and advertising purposes for all media, including, but not limited to, the internet.

10. Failure to attend the test does not relieve me of the obligation to pay the full fee for the test.

11. I acknowledge receiving a copy of this Agreement.

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 COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT OF THE LAW.
Release and Waiver of Liability and Indemnity Agreement (READ CAREFULLY BEFORE SIGNING).

In consideration of being permitted to participate in any way in the activities offered by Excel Martial Arts (the "Martial Arts Activities") and/or being permitted to enter for any purpose any restricted area (herein defined as any area where in admittance to the general public is prohibited), the parent(s) and/or legal guardian(s) of the minor participant named below agree to the following:

1. The parent(s) and/or legal guardian(s) will instruct the minor participant that prior to participating in the Martial Arts Activities, he or she should 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 until the situation is rectified. As a participant, I understand and agree that, if at any time, I feel anything to be UNSAFE; I will immediately take all precautions to avoid the unsafe area and REFUSE TO PARTICIPATE further.

2. I/We fully understand and acknowledge that:
1. There are risks associated with participation in the Martial Arts Activities, which could result in bodily injury, including partial or total disability, paralysis and death.
2. The social and economic losses and/or damages, which could result from these risks could be severe.
3. These risks may be caused by the action, inaction, or negligence of the participant or the action, inaction, or negligence of others, including, but not limited to, the Releasees named below.
4. There may be other risks not known to us or are not reasonably foreseeable at this time.
3. I/We accept and assume such risks and responsibility for the losses and/or damages following such bodily injury, disability, paralysis or death, however caused and whether caused in whole or in part by the negiligence of the Releasees named below.

4. I/We HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Excel Martial Arts, including its owners, directors, officers, employees, agents, contractors, and landlords of any premises used to conduct the Martial Arts Activities (herein referred to as "Releasees") from all liability to the undersigned, my personal representatives, assigns, executors, heirs, and next of kin for any and all claims, demands, losses or damages as a result of an injury arising out of participation in the Martial Arts Activities, including but not limited to the disability. paralysis, or death of the participant or damage to the property, caused or alleged to be caused in whole or in part by the negligence of the Releasees or otherwise.

5. I/We HEREBY acknowledge that the Martial Arts Activities are dangerous and involve the risk of serious injury and/or death and/or property damage. Each of the undersigned also expressly acknowledges that injuries received may be compounded or increased by negligent rescues or care operations or procedures of the Releasees.

6. EACH OF THE UNDERSIGNED further expressly agrees that the foregoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as is permitted by the law of the Province of British Columbia in which the event is conducted and that if any portion is held invalid, it is agreed that the balance shall, not withstanding, continue in the full legal force and effect.

7. On behalf of the participant and individual, the undersigned parent(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 guardian(s), will reimburse the Releasees for any money which they have paid to the participant, or on his or her behalf and hold them blameless.

8. I/We agree to for our minor child to participate in the Black Belt Test.

9. Excel Martial Arts or any party designated by Excel Martial Arts may photograph or film me while I attend the premises of any Excel Martial Arts Training Center and use any and all such photos, video footage and/or video streaming for promotion, sales, publicity, and advertising purposes for all media, including, but not limited to, the internet.

10. Failure to attend the test does not relieve me of the obligation to pay the full fee for the test.

11. I acknowledge receiving a copy of this Agreement.

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 COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT OF THE LAW.
Student Signature

Clear
Student's Name

First NameLast Name
Signature of Parent and/or Legal Guardian

Clear

Payment
I would like to pay: *all payments must be completed by the test date

The full amount todayIn 2 monthly payments by invoiceIn 3 monthly payments by invoice
Select your uniform and size in the payment area, then enter "Invoice" in the Coupon Code box to finish the registration.

A recurring invoice will be sent to you within 1-2 business days. You will be able to enter your credit card information at that time.

Black Belt Test and Uniform - Please choose one; Lightweight Uniform or Grappling Uniform*

Black Belt Testing + Lightweight Black Uniform Product Image

Black Belt Testing + Lightweight Black UniformUniform Size

$565.00CAD Lightweight Size

Black Belt Testing + Grappling Black Uniform Product Image

Black Belt Testing + Grappling Black UniformSizing: The first number is the equivalent lightweight uniform size, second number in parentheses is the Grappling Uniform Size - see sizing chart below

$615.00CAD Grappling Uniform Size

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Subtotal

$0.00CAD

Tax

$0.00CAD

Total

$0.00CAD

Payment Methods

Credit Card

Apple Pay

Google Pay

Grappling Uniform Sizing Chart
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Black Belt Test Registration

Student Information

Emergency Contact Information

Liability Waiver

Payment

Payment Methods