Martial Arts/Karate Participate and Release of Liability Form

Martial Arts/Karate Application to Participate and Release of Liability

Please complete the form below to sign up
Name of Student*

First NameLast Name
Address:*

Street Address

Street Address Line 2

City

Zip Code
Birth Date (ages 6+)*

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
E-mail Address *
Color of Hair*
Color of Eyes*
Have you taken Martial Arts or Karate classes before?

NoYes
What Martial Art or Karate rank are you currently?
Do you have any medical history or conditions that could affect your ability to participate in contact sports? *

NoYes (Please enter details)
Medical Conditions
Are you a member of a recognized National Martial Arts or Karate Organization?

YesNo
I am a member of:

United States Martial Arts AssociationUnited States Martial Arts FederationUSA Martial ArtsUSA KarateUSA JudoOther
Where did you hear about us?

A Friend or colleagueOnline Search (Google, Bing, Yahoo)P.C.C. IncorporatedMartial Arts WebsiteLocal Activities ListingNews ArticleOther
Payment Policy
I understand that P.C.C. Inc. and NICOBI GOJU-RYU KARATE-DO does not require members to sign a contract for an extended period of time, and members may cancel at any time by notifying a manager. I understand that there is a $50.00 annual membership fee and that my payment of $85.00 is due the first of every month. I understand that P.C.C. Inc. is a non-profit entity and relies on the prompt club/membership dues payments of members to stay open. A monthly invoice will be sent to me by email if my payment has not been received by the first of every month, either by credit card (via the hyperlink on the invoice), Cash, or Money Order payable to P.C.C. Inc. If I am unable to make a payment, I will notify a club manager and make an arrangement. Club dues are not tax deductible.
Payment Policy*

I have read and understand the payment policy
Membership Rules
MEMBERSHIP RULES Never leave the mat or the dojo without receiving permission from the instructor. No food, drink or chewing of gum are allowed on the mat. No non-karate activity is to take place during class time. Show your instructor respect by paying attention. Save the conversation for after class. Report all injuries to the instructor immediately. When arriving at class with an injury, the instructor must be notified prior to the start of class. Shoes are NEVER to be worn on the mat. Water bottles are permitted in designated area at mat-side. Water bottles are to have water or electrolyte beverages (like Gatorade) only. Never come to class under the influence of drugs or alcohol. Members are to keep their GEd's clean and in good repair. Finger and toenails are to be kept clean and trimmed to a reasonable length to prevent injuries to training partners. No jewelry may be worn during class unless specifically approved by the instructor. Members without uniforms should not have anything in their pockets. Karate involves physical contact and technical, and whatever you wear could become torn. No practicing of karate skills or new techniques is allowed without permission of the instructor. This includes techniques you learned on the internet, saw during a competition, or on a video. Spills are to be cleaned immediately. Trash should be placed in the proper container. Spectator chairs should be stacked at the end of class. Bullying is not tolerated in or out of the dojo. Members using their karate skills for bullying will not be allowed to return.
Membership Rules and Regulations*

I have read, understood, and accepted the rules for membership.
Privacy Policy
Video/Photo Release*

I understand that occasionally, photos and videos from club competitions and practices will be used in promotional material for the club. 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.
Confidentiality*

I understand that the club will never share my contact information for commercial purposes. I may, however, be contacted by the club managers about club announcements and information relevant to club membership.
Disclaimer and Waiver of Liability
Recognize and understand that martial arts/karate training 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 an instructor 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 martial arts/karate training 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 training practice and/or competition. If I have any injuries or illnesses that could affect my ability to participate, I will notify the club managers and coaches, and discuss the appropriateness of martial arts/karate training 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 NICOBI GOJU-RYU KARATE-DO or P.C.C. Inc. , 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,NICOBI GOJU-RYU KARATE-DO or P.C.C. Inc., 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.
Disclaimer and Liability Waiver*

I have read, understood, and accept the disclaimer and liability waiver and sign it of my own free will
Signature of Member or Legal Guardian*

Clear
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Martial Arts/Karate Application to Participate and Release of Liability

Payment Policy

Membership Rules

Privacy Policy

Disclaimer and Waiver of Liability