Release Form - Piscataway Dojo printable pdf download

Piscataqua D ojo / P iscataway D ojo

Release F orm

Date: .................................................................................................................................................

Student’s Full Name : ................................................................................... Male  Female

Students Birthdate:....................................................................................... Age: .........................

Street Address: ................................................................................................................................

City, State, Zip: ................................................................................................................................

Home Phone: ...............................................Work Phone: ............................................................

Email: ................................................................................................................................................

At times, we may take pictures and videos which may be used on the Internet

and/or for advertising purposes. Please INITIAL if you DO NOT want to

participate.

Contacts in case of Emergency:

Name:................................................................................................................................................

Phone Number: ...........................................(Home)........................................................... (Cell)

I, ......................................................................... , the undersigned, (hereafter, “The Student”)

hereby agree that in consideration of The Student being given the full rights and

privileges of membership in the Cuong Nhu Martial Arts Association, Piscataqua Dojo

and Piscataway Dojo (hereafter, “Association”). I shall hereafter and forever fully

release said Association, its agents, instructors, officers and directors, and all members

of said Association, from any cause of any claim or liability or damages or expenses,

including but not limited to any claims for personal injuries resulting from or arising

out of negligence of said Association, its agents, instructors, officers and directors or

members which may result from participation in martial arts training, instructions or

related activities

I am fully aware and expressly understand that training and instruction in the martial

arts requires strenuous exercise and activity and necessitates bodily contact during

sparring and at other times as part of the instruction in Association’s martial arts

training and I am fully aware that any and all of the aforementioned activities and

others may result either unavoidably or negligently in bodily injury to the student.

The Student warrants that he or she is in generally good health and physical condition

and that to the best of my knowledge does not suffer from high blood pressure, heart

ailments, or any other latent physical disabilities. If there are any physical conditions

that need to be considered, please list: ........................................................................................

............................................................................................................................................................

Student’s Signature (over 18 years)..............................................................................................

Parent’s Signature (under 18 years) .............................................................................................

Complete and Return this form with your registration.