Name
*
First Name
Last Name
Email Address
*
Phone
*
If using a US number, enter 1 as the country code.
Country
(###)
###
####
Date of Birth
*
MM
DD
YYYY
Address
Optional
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Martial Arts Experience
*
Please list and describe your martial arts experience and ranks.
Consent & Release of Likeness
*
1. The International Shinkendo Federation and Shinkendo Boston its affiliates, has requested permission to use my name, biographical or occupational description, phrases regarding me (or incidents or anecdotes concerning me substantially as set forth in an attachment which is made a part of this release), portrait, picture, likeness, or voice or any or all of them, in a recording, videotape, television production or reproduction, sound track recording, film strip, still photograph, CD-ROM, DVD, podcast, on an Internet site, blog, vlog, or other social media site or site with user-generated content including but not limited to Twitter, YouTube, Facebook, LinkedIn, in a printed publication or otherwise.
2. I hereby grant to The International Shinkendo Federation, Shinkendo Boston and its affiliates, its successors, assigns and anyone acting under its authority or permission the right to make originals where appropriate and to use for any lawful purpose (including publicity and other trade purposes) throughout the world and reproduce at any time in any form or manner and to copyright any of the items referred to in the preceding paragraph.
3. I hereby release The International Shinkendo Federation, Shinkendo Boston and its affiliates, its successors and assigns of and from any claim which I might otherwise have as a result of any such use, copyright or publication.
Waiver & Release of Liability
*
1. I agree that prior to participating, I will inspect the facilities and equipment to be used, and if I believe anything is unsafe, to immediately advise the instructors of such condition(s) and refuse to participate.
2. I acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including permanent disability and death, as well as severe social and economic losses, which might result not only from my own actions, inactions or negligence but the actions, inactions or negligence of others, the rules of play, or the conditions of the premises or of any equipment used. Further, there may be other risks not know to myself or others at this time.
3. I assume all the forgoing risk & accept responsibility for damages following such injury, permanent disability, death or severe social & economic losses. I accept full financial and treatment responsibility for any injuries received.
4. I release, waive, discharge and covenant not to sue Shoshinkan Shinkendo Dojo, the International Shinkendo Federation (ISF), the Chinese Consolidated Benevolent Association of New England (CCBA), its affiliated clubs, their respective administrators, directors, agents, coaches, instructors and other supervisors, coaches, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessee’s of premises used to conduct the event(s), or classes, all of which are hereafter referred to as “releases”, from any and all liability to each of the undersigned, his/her heirs, and next of kin for any and all claims, demands, losses or damages on account of injury, including permanent disability, death or damage to property, caused or alleged to be caused in whole or in part by the negligence of the releases or otherwise.
Emergency Contact
*
Who should we contact in the event of an emergency?
First Name
Last Name
Emergency Contact Phone #
*
Where should we reach your emergency contact?
Country
(###)
###
####
