Text Box: Martial Arts After School Summer Camp Waiver/Release Form Student’s Name:____________________________ Age: ______ Birthday ___/___/___ Address: __________________________________________________ City: ___________________Zip:__________ Home/Cell Phone: (_____)_____________ Work/ Emergency Phone: (_____)______________ E-mail Address: _________________________________@_______________________ Physical injuries or body problems (past or present): ______________________________________________________________ Student/Martial Arts After School (MAAS) representations and release of liability: The Parent/ Legal Guardian signing this waives any cause of action or claim against Martial Arts After School, AND/OR Eric Protas AND/OR Protas Development Inc. ( D.B.A: PMAI (or Protas Martial Arts Instruction) or D.B.A. the Allied Gardens School of Martial Arts); their officers, directors, instructors, and employees for any injuries received resulting from instructional services rendered. The Parent/ Legal Guardian signing this acknowledges that they should have had their child received permission from a medical doctor following a general physical examination approving the student’s participation in these instructional services. The member applying warrants and represent that he/she/minor or student is in good physical condition and has not been advised by any Physician or Medical Facility that participation in the applied for course of training will in any way be adverse to the well being of the student. Furthermore, member represents that the student is able and allowed to participate in exercise and various martial arts curriculum which is provided by Martial Arts After School (Hereafter MAAS). Student/parent/guardian understands that by participating in the martial arts program or by use of the facilities or equipment covered by this contract does present the possibility of accidental injury. Student/parent/guardian assumes all risk associated with such participation within this program and holds MAAS harmless for any such injury or occurrence. In addition, student/parent/guardian agrees to indemnify MAAS from any and all liability which may arise against MAAS by such member or though any other third party as a result of training received by MAAS or by use of MAAS’s facilities or equipment. Student/parent/guardian understands that during the course of instruction, employees or higher degree student instructors of MAAS will be engaged in a course of conduct requiring physical contact, and he/she (or parent or guardian) gives full consent to such contact as is required by the training. It is understood that due to the nature of the training which is being provided by MAAS that accidents do from time to time occur. While all precautions will be taken to assure the safety of all students, it is impossible to guarantee that such accidents will not occur. In the event that you are involved in an accident which subjects you to any injury, you agree to hold MAAS, Protas Development Inc (DBA: Protas Martial Arts Instruction (PMAI) and DBA: Allied Gardens School of Martial Arts) and Eric Protas harmless; you further agree that neither you, a parent, a guardian or any other financially responsible person will take action against MAAS, Protas Development Inc (DBA: Protas Martial Arts Instruction (PMAI) and DBA: Allied Gardens School of Martial Arts) and Eric Protas as a result of such injuries. Age or Parental Consent Certification: By signing this contract, you are certifying that you are either of legal age or that you are signing this contract as the parent or legal guardian of a minor, and by signing this contract on behalf of any minor, you hereby agree that you shall be responsible for all payments due hereunder and that you will indemnify and hold MAAS harmless for any injuries, losses, or damages sustained to anyone as a result of the minor’s participation in this program of instruction. Page 1 Governing Law: This agreement shall be construed in accordance with the laws of the State of California without regard to its conflict of laws principals. This Agreement shall constitute the entire understanding with respect to the subject matter hereof and may be modified only in writing signed by both STUDENT and MAAS. If any provision of this Agreement is determined to be invalid, illegal or unenforceable, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or impaired thereby. Bad Check Charges: It is agreed that in the event that MAAS receives any check returned as NSF or is returned by bank for any other reason, that student/parent/guardian will be responsible for a charge of $6 made payable to MAAS. Weapon Purchase and Use: Use and misuse of Martial Arts padded and wooden weapons purchased or made at the MAAS Martial Arts Summer Camp involves serious risks, including injury, disability and death. Weapons are sold only for training under expert supervision, for demonstration of forms, collection or display. Inspect weapons before each use to ensure they are in proper condition. If any unsafe condition is observed, do not use this product. Do not use weapons for sparring or contact as they are not constructed or meant to be used for sparring or contact, unless under the direct supervision of an instructor at the MAAS Martial Arts Summer Camp . User assumes all risk of injury from any use. Students may only practice with this weapon with the parent’s permission. Only students enrolled in the MAAS Martial Arts Summer Camp may use this weapon. I understand, as the purchaser of this weapon, the inherent risk involved in the use of any weapon and that I will not hold liable MAAS, Eric Protas, The Allied Gardens School of Martial Arts (hereafter AGSMA) or Protas Martial Arts Instruction (hereafter PMAI) for the correct or incorrect use of weapons purchased from MAAS, Eric Protas, AGSMA or PMAI or any injury or damage that may result. I also understand that the construction of the weapons involves the use of PVC pipe, which may break if struck, and I understand my child is not to use this weapon in a manner that involves contact with other persons or objects, and further I will not hold liable MAAS, Eric Protas, AGSMA or PMAI should my child use this weapon in this manner. Neither MAAS, Eric Protas, AGSMA nor PMAI make any warranties either expressed or implied that items sold are merchantable or fit for a particular purpose. Group Photo Consent/ Opt Out Option: I (the undersigned) do hereby confirm the consent heretofore given you with respect to your photographing me or my child in connection with your MAAS Martial Arts Summer Camp and I hereby grant to you, your successor, assigns and licensees the perpetual right to use, as you may desire, all photos which you may make of me or my child, and the right to use my name and/or child’s name or likeness in or in connection with the exhibition or any other use of such photograph. By checking the box here ¨ I DO NOT GIVE CONSENT for my child’s photo to be taken or used during the MAAS Martial Arts Summer Camp and further understand I am no longer eligible to receive the free group photo given at the end of MAAS Martial Arts Summer Camp. Medical Release: In case of emergency, if family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel. (i.e. EMT, First Responder, E.R. Physician) Family Physician: ______________________________ Phone: _______________ Address: ____________________________________________________________ Hospital Preference: __________________________________________________ In case of emergency contact: ___________________________________________________________________ Name Phone Relationship to Student ___________________________________________________________________ Name Phone Relationship to Student Please list any allergies/medical problems, including those requiring maintenance medication. (i.e. Diabetic, Asthma, Seizure Disorder) Please give: Medical Diagnosis /Medication/ Dosage /Frequency of Dosage. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment. Date of last Tetanus Toxoid Booster: _____________________________________ PARENTS/GUARDIAN: Authorization for Student who is a Minor Parent’s Signature: _______________________________ Relationship: _______________ Print Name: __________________________________ Date: ____/____/____ Page 2