Please print & mail or fax (972-243-2666) this form with your $75 payment made payable to:
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OKCD
13250 Branch View Lane
Dallas, TX 75234

Name:

Address:

Email:  

 Telephone:
Dojo Name:   Sensei Name:
Years of Training:
Emergency Contact: Telephone:

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WAIVER AND RELEASE OF LIABILITY

I the undersigned, in consideration for being permitted to participate in the Okinawan Karate Fall Training 2006:

1. I ACKNOWLEDGE, agree, and represent that I understand the nature of the activity and that I am qualified, in good health, and in proper physical condition to participate in such activity. I further agree and warrant that if at any time I believe conditions to be unsafe, I will immediately discontinue further participation in the activity.
2. I FULLY UNDERSTAND that: (a) ATHLETIC ACTIVITIES INVOLVE RISKS AND DANGERS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH (“RISKS”); (b) these risks and dangers may be caused by my own actions or inactions, the actions or inactions of others participating in the activity, or the condition which the activity takes place.
3. I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation or that of the minor in the activity. If any, while attending or participating, and I hereby waive all claims against, including but not limited to, The Okinawan Karate Club of Dallas, Inc., Howard Johnson Deerfield Beach Resort, all sponsors, instructors, students, event organizers, parents/guardians, and volunteers for any damages, injuries or losses that I may sustain. I fully understand that any medical treatment given will be of a first aid treatment only. The authorization includes tendering or failure to render and/or acceptance of any medical aid, medical care, hospitalization and / or any other assistance deemed necessary for the proper care and well being of myself and/or the minor below, I do hereby accept the conditions in full. I waive all rights to compensation in regards to any photographs or video tapes furnished by or taken of me in connection with the Fall Training and I give full permission to those associated with this event for use in publication, promotion, or publicity now or in the future.

IF UNDER 18 YEARS. RELEASE AND CONSENT MUST BE SIGNED BY PARENT / GUARDIAN.

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Signature of Participant

________________
Date

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Signature of Parent / Guardian

________________
Date

AUTHORIZATION CREDIT CARD

I hereby authorize my credit card company to make my payment for the seminar to the Okinawan Karate Club of Dallas, Inc. for $75.00. 

VS  MC     Name on Card: ________________________________________           Card No:_______________________________________________         Exp. Date: ____________

 

 

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