Name of Participant
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First Name
Last Name
Gender
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Female
Male
Date of Birth
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MM
DD
YYYY
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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Email
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Emergency Contact
First Name
Last Name
Emergency Contact Relationship
Emergency Contact Phone
(###)
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Personal acknowledgement of risk and waiver of claim.
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I, the undersigned, hereby release the owners, instructors, assistants, and all fellow participants and their families of the organizations known as "East Coast Training Systems LLC" and "Bunker Hill Karate" from any and all claims of any nature whatsoever stemming from my attendance or participation, or the attendance or participation of the group I represent or the minor in my charge, in the above named training activity/activities including, but not limited to physical illness, personal injury, and/or bodily harm that I/they/he/she may sustain and I further waive my/their/his/her rights at law to file any further claim.
I Agree
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I understand and agree as a participant, parent or responsible adult in the case of an activity that includes minor children in my charge, in the above stated activity/activities, to release East Coast Training Systems LLC and Bunker Hill Karate, its owners, instructors, assistants, and all fellow participants and their families from any and all actions and liabilities, claims, or suffering now and unknown which may be sustained by me, or those in my charge, regardless of any negligence or other action and conduct. I, the undersigned, assume all risks.
I Agree
Covid-19 and contagious illness Waiver
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I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is believed to be extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.
East Coast Training Systems LLC and Bunker Hill Karate have put in place preventative measures to reduce the spread of COVID -19 and other contagious illnesses; however we cannot guarantee that you, your children, the minors in your charge will not become infected with COVID-19.
I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I, my children, or the minors in my charge may be exposed to or infected by COVID-19 by attending activities at or hosted by East Coast Training Systems LLC and Bunker Hill Karate, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at East Coast Training Systems LLC, or any activity associated with East Coast Training Systems LLC and Bunker Hill Karate, may result from the actions, omissions, or negligence of myself and others, including but not limited to instructors, assistants, and all fellow participants and their families.
I voluntarily agree to assume all of the foregoing risk and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance at East Coast Training Systems LLC or activities it hosts. On my behalf, and on behalf of my children or minors in my charge, I hereby release, covenant not to sue, discharge, and hold harmless East Coast Training Systems LLC and Bunker Hill Karate, its owners, instructors, assistants, and fellow participants, of any claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of East Coast Training Systems LLC and Bunker Hill Karate, its instructors, assistants, trainers and representatives, whether a COVID-19 infection occurs before, during, or after participation in any East Coast Training Systems LLC or Bunker Hill Karate program.
I Agree
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In consideration of the furtherance of your purposes, objectives, and work, and in consideration of your permitting me to participate in the above named activity/activities, on behalf of myself, my heirs, executors, administrators, and assigns, and those in my charge, I hereby waive and release any and all rights and claims for damages that I, my children, or those in my charge, may have or incur during participation in the above named activity/activities, or any activity/activities associated with East Coast Training Systems LLC and Bunker Hill Karate, against you, the facilities in which the activity is held, as well as any other person or organization connected to the above stated activity/activities, East Coast Training Systems LLC, Bunker Hill Karate, owners and instructors, their heirs, executors, successors and assigns, for any and all illnesses and/or injuries that I, or those in my charge, may incur while participating in the above stated activity/activities, and any time before and after said activity/activities. I confirm that I, my children, or those in my charge, are cleared by a physician to participate in physical activity and have no known health restrictions. I also release the rights, without further compensation to me, to any photographs or video in which I, or those in my charge, may be a part of, either as the subject or in the background, to Bunker Hill Karate for promotional purposes (website, flyers, social media, etc.) which are decent and relate to the services provided by Bunker Hill Karate. My signature below confirms that I have read, understand, and agree with the above terms. I also acknowledge as a parent, group leader, event organizer, instructor, parental supervisor, teacher, or principal that I am responsible for those in my charge.
I Agree
I have read and understand the above acknowledgement of risk and waiver of claim.
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Yes
Name of responsible party
(if different from participant)
First Name
Last Name
Relationship to participant
Phone Number
(if different from participant)
(###)
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Signature
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