Name of Applicant/Guardian/Yourself

Name of Student

Phone Number

Date of Birth

Please list any important medical history, physical or medical limitations or allergies we should be aware of so that we take better care of the participant/s or your child:

Waiver and Release I hereby WAIVE AND RELEASE KENPOKAI(to be known as the “Released Party”) from liability pertaining to the matters set forth below. I understand that by submitting this Waiver and Release, I express and willingly agree to assume complete responsibility for any risk of injury that may arise from the below related activity. On behalf of myself, my child, my heirs, my assigns and next of kin, I waive all claims for damages, injuries and death sustained to me (or my child) or my property that I may have against the above named Release Party relating to such activity. I understand that the activities I or my child will participate in may be dangerous and may cause serious injuries, including bodily injury, damage to personal property and/or death. By this waiver, I assume any risk, and take full responsibility and wave any and all claims of personal injury, including severe bodily injury, damage to personal property and/or death relating to all activities associated with KENPOKAI, including but not limited to receiving lessons at the facility, using the facility and it’s equipment, practicing and engaging in Martial Arts activities, and related activities on and off the school premises. If my child is injured from said activity, I will not hold Released Party responsible even if the injuries were caused by negligence on my part or the Released Party, or any other party under or affiliated with the above named Release Party. I do not have any physical limitations, mental ailments, physical or mental disabilities that would limit or prevent my child from participating in the above-mentioned activity, and, if required, will obtain a medical examination and clearance. I HAVE READ AND FULLY AGREE TO THE TERMS OF THIS WAIVER AND RELEASE. I UNDERSTAND AND CONFIRM THAT BY SUBMITTING THIS WAIVER AND RELEASE I HAVE GIVEN UP CONSIDERABLE FUTURE LEGAL RIGHTS. I HAVE SIGNED THIS WAIVER FREELY, VOLUNTARILY, UNDER NO DURESS OR THREATS OF DURESS, WITHOUT INDUCEMENT, PROMISE OR GUARANTEE BEING COMMUNICATED TO ME. MY SIGNATURE submission IS PROOF OF MY INTENTION TO EXECUTE A COMPLETE AND UNCONDITIONAL WAIVER AND RELEASE OF ALL LIABILITY TO THE FULL EXTENT OF THE LAW. I AM 18 YEARS OF AGE OR OLDER / LEGAL GUARDIAN AND MENTALLY COMPETENT TO GRANT THIS WAIVER. By submitting this form you are agreeing to this waiver

Media Release form I(as mentioned in this form), grant permission to KENPOKAI hereinafter known as the “KENPOKAI” to use my image (photographs and/or video) for use in KENPOKAI media publications including: Videos, Email Blasts, Recruiting Brochures, Newsletters, Magazines, General Publications, Website and/or Affiliates, Other: distributions I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image. "I am of legal age (18 years or older) and competent to contract in my own name. I have read this release before signing below and fully understand its contents, meaning, and impact. I acknowledge that I am free to address any specific questions about this release by submitting them in writing before signing. I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release. OR I am the parent or legal guardian of the below-named child. I have read this release before signing below and fully understand its contents, meaning, and impact. I acknowledge that I am free to address any specific questions about this release by submitting them in writing before signing. I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release. I HAVE READ AND FULLY AGREE TO THE TERMS OF THIS WAIVER AND RELEASE. I UNDERSTAND AND CONFIRM THAT BY SUBMITTING THIS WAIVER AND RELEASE I HAVE GIVEN UP CONSIDERABLE FUTURE LEGAL RIGHTS. I HAVE SIGNED THIS WAIVER FREELY, VOLUNTARILY, UNDER NO DURESS OR THREATS OF DURESS, WITHOUT INDUCEMENT, PROMISE OR GUARANTEE BEING COMMUNICATED TO ME. MY SIGNATURE submission IS PROOF OF MY INTENTION TO EXECUTE A COMPLETE AND UNCONDITIONAL WAIVER AND RELEASE OF ALL LIABILITY TO THE FULL EXTENT OF THE LAW. I AM 18 YEARS OF AGE OR OLDER / LEGAL GUARDIAN AND MENTALLY COMPETENT TO GRANT THIS WAIVER. By submitting this form you are agreeing to this waiver "

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