Shin’s Family Martial Arts Center
27935 Smyth Drive
Valencia, California 91355
(661) 257-6767
Participants Name______________________________________
Address (Street) _____________________________________________ Phone _______________
City _________________________ Zip Code ____________ Date of Birth ___________________
I, the above named participant, hereby declare that I have been informed of the inherent dangers involved in engaging in Trampoline, Tumbling, Bungee, Rock Wall and Martial Arts and related activities, I fully realize and clearly understand that I am placing myself in danger of possible bodily injury. It is with full realization and clear understanding of the aforementioned dangers that I agree to become a participant in these activities and hereby agree to the following terms as a condition for participation: That during and at all times that I am a participant in Trampoline, Tumbling, Bungee, Rock Wall and Martial Arts and any related activities. I shall be liable for any and all injuries I sustain or incur during and related to participation in Trampoline, Tumbling, Bungee, Rock Wall and Martial Arts the course of instruction, preliminary exercises, and related activities and will not hold, the sponsor(s), its governing body(ies) , officials, employees, employees and members, either individually or otherwise, liable for any such injuries or any loss or damages arising therefrom. I also realize that I am responsible for providing my own medical insurance or medical coverage, any and all medical expenses I might incur in participating in these activities. That I, intending to be legally bound, hereby for myself, my heirs, executors, and administrators, waive and release any and all rights to damages or claims I have against the sponsor(s), Its governing body(ies), officials, employees and members, either individually or otherwise, for injuries or rights to damages suffered by me, directly or indirectly, including any future psychological and/or physical pain and suffering claims, as a result of attending, participating in, practicing for, traveling to or from such activity, or against the owners, organizations, governing body(ies), employees, members or instructors(s), either individually or otherwise, of the gymnasium, Dojang, school, or place where held. That I also agree to defend, indemnify, and hold the sponsor(s), its governing body(ies) or employees, or the instructors of the program, either individually or otherwise, harmless from any claims and action by third parties alleging injury from my use of the techniques and skills learned during and related to the course of instruction, preliminary exercises, and related activities.That I have consulted with my physician and that I am in proper health and physical condition to participate in the activities listed above.That I further agree to follow all rules and instructions as stated by the staff/instructors in the facility. That I waive any and all rights to compensation, in any form, for pictures, films, or videotapes taken of me in the above activity and grant permission for them to be used for any publicity or publication purposes. I further agree that the execution of this agreement is consideration, in part, for participating in Trampoline, Tumbling, Bungee, Rock Wall and Martial Arts. I understand that my failure to execute this agreement would result in my not being able to participate in such activities, preliminary exercises, and related activities conducted by the instructors/staff of this program through the sponsoring agency. This agreement is to remain in effect until revoked in writing and such written revocation is delivered to the Shin’s Family Martial Arts Center LLC or its authorized representative.
_______________________________/__________ _________________________/_________ Participant’s Signature Date Parent’s or Legal Guardians Signature Date
Important…….. If participant is under age 18 years of age, parent or legal guardian must sign above
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