UA-13043593-1

INDEMNITY AND RELEASE OF LIABILITY

The undersigned individual wishes to study, participate, and train in karate classes being taught by, or under the direction of, Marco Maciel (“Maciel”) at the Zen Life and Meditation Center, Chicago (“ZLMC”).  In consideration for such study, participation, and training, such individual (“I”) and, if such individual is a minor, such individual’s parent or legal guardian (“I/we”), hereby freely and knowingly (a) make the following representations and warranties and (b) accept and agree to the following terms and conditions:

  1. Representations and warranties.  
    1. I/we understand that I should be in good general physical condition to participate in the vigorous activities associated with karate training, and I am in good general physical condition. ____ (initial)
    2. I do not have any medical condition that could pose a hazard to myself or fellow students.  ____ (initial)
  2. Assumption of Risk.  I/we understand that karate is a hazardous activity that involves inherent risks of serious injury.  With full knowledge of the risks involved in karate, I/we expressly assume all of the risks of harm to myself arising from, or related to, the practice of karate. ____ (initial)
  3. Release of Claims and Waiver of Liability.  I/we hereby expressly and for all time, on behalf of myself and my heirs, successors and assigns, executors, and personal representatives, release and agree to hold harmless Maciel and ZLMC (and any and all employees, agents, or volunteers of Maciel or ZLMC) from any and all claims, demands or causes of action, whether at law or in equity, that arise or might arise from my study, participation, and training in karate, my use of any related equipment, my participation in any activity associated directly or indirectly with Maciel or ZLMC, or my use (or attempted use) of karate techniques; and ____ (initial) 
  4. Indemnification.  I/we hereby agree to indemnify and hold harmless Maciel and ZLMC (and any and all employees, agents, or volunteers of Maciel or ZLMC) from any and all claims, demands or causes of action, whether at law or in equity, that arise or might arise from my study, participation, and training in karate, my use of any related equipment, my participation in any activity associated directly or indirectly with Maciel or ZLMC, or my use (or attempted use) of karate techniques, including, but not limited to, any claim of personal injury (whether physical or mental) that may be asserted against them.  ____ (initial)

 

STUDENT NAME (PRINTED): ____________________________________________________

STUDENT DATE OF BIRTH: _______________________  AGE: ______________________

STUDENT ADDRESS: ____________________________________________________

CONTACT INFORMATION (cell and/or email): ____________________________________________________

STUDENT SIGNATURE:  ____________________________________________________

DATE: ____________________________________________________

 

APPROVAL AND ACCEPTANCE BY PARENT OR LEGAL GUARDIAN

(if student is under 18 years old)

 

The undersigned, being the parent or legal guardian of _____________________________, has read the foregoing, understands the same, and does hereby make the aforesaid representations and warranties, and accept and agree to the terms and conditions of the foregoing Indemnity and Release of Liability, on behalf of myself and the said minor, intending to be legally bound hereby.

 

PARENT/GUARDIAN NAME (PRINTED): ____________________________________________________

CONTACT INFORMATION (cell and/or email): ___________________________________________________

PARENT/GUARDIAN SIGNATURE:  ____________________________________________________

DATE: ____________________________________________________

Student’s Conduct and Payment Policy.

  1. I hereby confirm that I will conduct myself with proper, healthy, safe, respectful and responsible behavior, as per the five (5) Karate-do Dojo Kun (Principles), of which I am aware, and I will uphold the standards of decorum of the JKA WF CHICAGO KARATE INSTITUTE, INC. (“JKA WF CKI”). 
  2. I shall be prompt for my classes and considerate towards the time and efforts of my fellow students and Instructors.
  3. I shall pay my tuition/dues in advance.  I understand that a late charge of $25 per class may be added to any tuition/dues not paid in advance of the class.  I understand that, once paid, tuition/dues are non-refundable.
  4. I understand that ZLMC, Maciel, and the JKA WF CKI have the right to exclude me from class for any reason (including delinquency in paying tuition/dues) or for no reason.
  5. I understand that, in order to be permitted to test for my grades, compete in tournaments, and attend events endorsed by the JKA WF CKI, I need to be current with my tuition/dues and annual membership fees, and I must exhibit good conduct and constant progression in technique.

 

STUDENT SIGNATURE:  ____________________________________________________

PARENT/GUARDIAN SIGNATURE:  ____________________________________________________

(if participant is under 18 years old)

 

REFERRED BY: ____________________________________________________