Enroll in Karate Classes "*" indicates required fields Participant's Name* First Last Parent/Guardian's Name First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Birth Date* MM slash DD slash YYYY Age*Please enter a number from 1 to 100.Home Phone*Cell PhoneEmergency PhoneEmail* List a brief history of your martial arts experience*Including styles and time trainedHow Did You Hear About the Eugene School of Karate?*Use “Other” to share who referred you, if applicable! Brochure Newspaper Demonstration Website Flyer Other Do you have problems in any of these areas? Athsma Epilepsy Orthopedic or back Heart Diabetes Any other health issues we should know about? Terms & Conditions*Risk Agreement I, the undersigned, give instructors, staff, and responsible adults the power to authorize medical or other treatment of the person named above under “Participant’s Name”, subject to the limitations below, if any. If I am not the person so named, I am the parent, guardian or responsible adult for the person named, and I have the legal right to grant this power. Treatment may be made without regard to whether I or any other parent, guardian or responsible adult has been contracted or has consented to the specific treatment, provided it does not conflict with the limitations outlined below. This authority begins on the date signed and continues indefinitely By giving my authorization, I assume responsibilities for all decisions made, provided they are reasonable decisions, and I trust their judgment and offer the benefit of the doubt to them in any claim or legal proceeding. This presumption may only be overcome by clear and convincing evidence that they acted with malice or willful gross negligence, and, if so, they may still be liable. I understand that the instructors and staff, whether paid or volunteer, may have some skills in first aid, CPR, and, at their discretion, I authorize them to use those skills and techniques to assist in any circumstance in which they judge their skills would be necessary or helpful Advisory of Rights and Responsibilities Safety is not the sole responsibility of the instructors and staff. Everyone in class is responsible for their own safety and the safety of those around them. All students have the right and responsibility to excuse themselves from any exercise they believe will be harmful to them. All students must evaluate each situation in the context of their skill and current physical condition and conduct each drill in a manner that is safe. If an instructor gives an instruction that is unsafe for the student, it is the student’s responsibility to inform the instructor that the skill may be unsafe for them. The instructor will routinely excuse the student from unsafe exercises and drills. All students have a responsibility to train and conduct themselves in a manner that helps all students and instructors remain safe. Students must give those who are training enough room to avoid interfering and avoid being accidentally struck by someone else practicing. In the event of an injury, students have the right and responsibility to evaluate the extent of harm, stopping what they are doing even if it includes a partner, and determining if it is safe to continue. Unless a student is certain that further practice will not create or worsen a problem, all students are encouraged to stop what they are doing and inform an instructor. In the event of a serious injury or appearance of a serious injury, all students, instructors, staff and visitors, notably parents have the right to call a stop to a particular training exercise. If a student notes an unsafe training situation or anything else that may cause or lead to harm of students, instructors, staff, visitors or guests, then the student is expected to correct the situation if within his ability or notify an instructor or staff member immediately. Assumption of Responsibilities and Risk Martial arts is a potentially dangerous activity. Bumps, bruises, scrapes, scratches and soreness are commonplace, and most students will encounter this sort of minor injury from time to time in their training. More serious injuries are possible, including sprains, strains, twists, cramps, and injuries similar in magnitude, and students can expect to encounter these injuries infrequently. The possibility of more serious injuries exists, including fractured bones, broken bones, torn ligaments,, though not all students encounter such serious injuries. There remains, despite safety precautions, the remote possibility of crippling or death, though this is certainly not expected in martial arts class. I understand the above statement of risk, and I understand the rights and responsibilities of students. I assume responsibility for my own safety (or the safety of my child), understanding and accepting the risks involved with martial arts training. Even if the instructor has informed me that no serious injuries have ever happened in this school, or with any of the instructors, I understand that this does not mean that there is no possibility of harm. By assuming this risk, I completely absolve all instructors, staff, guests, landlords, management companies and any and all other parties of liability for my harm, unless intentionally caused in criminal conduct. Notice of Non-certification for Instruction The martial arts classes taught at the Eugene School of Karate, Inc. are not designed to teach, certify, or license participants to instruct martial arts classes or techniques. Due to safety and licensing concerns, when signing below, you agree not to teach martial arts classes elsewhere without signed consent from the officers of the Eugene School of Karate, Inc. Use of Image The undersigned agrees that the Eugene School of Karate, Inc. may use his/her image, or the image of his/her child, for any marketing or publication used in advertising the school. Photographs or other images procured by the Eugene School of Karate, Inc. are the property of the school. Notice and Consent to Instructors This school seeks to make use of highly trained, professional instructors, with both expertise and experience both in the art we teach and in teaching. Classes may be taught by the head instructor or any other qualified instructor. Should an instructor be unavailable for a given class, a junior instructor, senior student or guest instructor may teach. The choice of the instructor is left to the discretion of the school. I understand that I may not always have the instructor I desire, but I shall seek to learn from whomever is teaching, to show the respect due the position of teacher to whomever is teaching, and to conduct myself in accordance with the etiquette established in the school. I understand that I have the responsibility for my own safety without regard to who is teaching the class. I specifically consent to any instructor the school, instructors or staff feel are sufficiently qualified by any standards they set to teach the class. I specifically understand and agree that the full force of this document applies no matter who is teaching. Notice of Physical Contact Martial arts training involves a wide variety of skills and techniques. While practicing these skills, students may have contact with any portion of the body. The groin may be the target of kicks and strikes. The chest, buttocks, groin, or any part of the body may be contacted by any part of the training partner’s body during training by martial arts techniques, or incidentally contacted while performing a martial arts technique targeting another portion of the body. When male and female students train together, or when adult and minor students train together, and in any other training combination, the purpose and intent of the school, instructors and staff is to provide an environment for all students to learn and practice martial arts. Students are expected to conduct themselves appropriately at all times to ensure the best training results for everyone. Should any student feel a training partner is engaging in contact beyond the scope of training, or a training partner is taking undue and unacceptable advantage of training contact, or if a student is made uncomfortable by any training exercise or partner, then that student has the right to withdraw from the exercise or drill. If the conduct of the training partner appears inappropriate, the student should inform the instructor privately. If the conduct of the training partner, or any training partner, appears criminal, then an instructor should be informed and the authorities may be notified either by the student or the instructor, or both. Consent to Physical Contact I understand the nature of the physical contact in martial arts training, and I understand that I have the right to immediately withdraw from any exercise or drill in which the conduct of any party seems beyond the scope of training or makes me uncomfortable. I agree to abide by school etiquette in all matters pertaining to training, and I shall not in any way conduct myself inappropriately or take inappropriate advantage of the contact martial arts training allows. Indemnification by Parents Applicable only to Parents Enrolling a Minor Child I agree not to bring any claim or suit against the school, instructors, staff, guests, students, landlord, or any other parties on behalf of my child for any injury or harm sustained by any event short of a criminal act, and then only the criminal shall be the subject of such a claim. I further agree that I will not cause to be brought, nor encourage a claim or suit. I also agree not to cooperate in the bringing of such a suit or claim except insofar as I may be legally required to do so. Finally, I shall indemnify the school instructors, staff, guests, students and any and all additional defendants covered by this agreement for all judgments, costs, attorney fees and other expenses incurred as a result of a breach of this agreement. Arbitration Clause Should any dispute arise between me, my child, or anyone acting on behalf of my child, regarding this school, then I specifically agree that the dispute shall be resolved in binding arbitration. Should a suit be filed in Court, I specifically authorize the Court to order the case to binding arbitration. Severability If any clause, sentence, phrase or statement is found unenforceable or invalid by any Court of law, the remainder of the document shall remain valid, enforceable and the invalid clause, sentence, phrase or statement shall be considered struck from the document. Durability This document is effective from the date signed with no expiration. Furthermore, the terms of this document are retroactive to the beginning of training and visiting the school if this document was signed after that date. Financial Agreement The Eugene School of Karate, Inc. agrees to provide the Participant with lessons in the martial arts on a schedule basis established by the Eugene School of Karate, Inc.; each lesson to be approximately one hour in duration for adults, teens, and youth; one-half hour for preschool and kinder age children. Lessons scheduled may be modified at the discretion of the Eugene School of Karate, Inc. from time to time for holidays, tournaments, seminars and other Eugene School of Karate, Inc. events and activities. The Eugene School of Karate, Inc. shall give prior notice of such modifications by general announcements, emails, texts and newsletters. Participant recognizes that regular class attendance is important for student progress and understands that the Participant is obligated to make payments whether or not Participant attends classes. Participant has the option to cancel this agreement within 72 hours and obtain a refund less any down payment, registration fee and equipment fee. In the event of a late payment, a charge of $35.00 will be assessed the Participant. I agreeLimitations to Treatment Information of Medical Significance Start Date* MM slash DD slash YYYY Participant's Signature*Parent/Guardian SignaturePhoneThis field is for validation purposes and should be left unchanged.