Event Waiver - Encinitas Karate

DUE TO INSURANCE REQUIREMENTS, GUESTS WILL NOT BE ADMITTED TO ANY EVENT WITHOUT A FULLY COMPLETED AND SIGNED PERMISSION SLIP (we do not share your information with anyone.)

Parent/Guardian Information: First Name *

Last Name *

Email *

Cell Phone *

Guest/Minor Information: First Name *

Last Name *

Age *

Date of Birth *

Name of School Attending *

For 18 Yrs. and Younger

Which event type is this for? Which event type is this for?

Birthday Childs Name or Buddies Name

Applicant/undersigned agrees to indemnify and hold harmless Encinitas Karate, Inc., its officers, directors, volunteers, officials, staff and contractors from any and all liability, losses, or damages whatsoever, including emotional damage, arising from participation in any of their programs. In case of an accident or other emergency, personal/officers/directors of Encinitas Karate, Inc. are hereby authorized to secure medical care deemed necessary as a result of accident or injury for the participant. I further agree to pay any and all costs incurred as a result of this treatment. I hereby irrevocably consent to and authorize the use and reproduction of photographs and video taping of any Encinitas Karate Inc. event for promotional; use or the Dojo's Website. Such footage may be used in any manner deemed appropriate by Encinitas Karate Inc. without compensation.

Guardian or Student Signature *

Clear

Date *