RO INSLER TAEKWONDO

973-777-4741 ~ Fax 973-777-4742 ~ Cell 201-697-8799 ~ TKDteach2@aol.com ~ www.RoInslerTKD.com

Mailing Address: 23-26 Berkshire Road, Fair Lawn, NJ 07410

STUDENT PARTICIPATION & RELEASE FORM

PLEASE CAREFULLY READ BOTH PAGES COMPLETELY AND SIGN WHERE INDICATED.

Fill out this form in ink, and please do not leave anything blank.

Participation will not be permitted without this form. Your cooperation and immediate response is appreciated.

STUDENT’S INFO:

1. Student’s Name ___________________________________ 2. Date of Birth ______________

3. Address _________________________________ City, State Zip____________________________

4. Students E-mail ________________________________ 5. Cell #_____________________________

6. Home # ________________________ 7. Student’s Work # (if any) __________________________

8. Emergency Contact _________________________ Tel. # __________________ Relationship:_______________

9. Medical Conditions/Limitations (please list each if any, or if you have none, write “None” - do not leave space blank) ________________

____________________________________________________________________________________________________________________

10. Medications (list each, if any, or write “none“– do not leave blank)_________________________________________________________

PARENT’S/GUARDIAN’S INFO: Complete the following if the student is a child (age 17 and under):

a) Mother __________________________Resides with Y / N Cell__________________ Work__________________

Mother’s Email_____________________________ Address (if different from student) ____________________________________

b) Father __________________________ Resides with Y / N Cell__________________ Work__________________

Father’s Email______________________________ Address (if different from student) ____________________________________

c) Guardian ________________________ Resides with Y / N Cell__________________ Work__________________

Guardian’s Email___________________________ Address (if different from student) ___________________________________

OTHER CONTACT: Complete the following if student is an adult (age 18 and up) circle whichever applies:

Spouse / Roommate / Closest Relative / Other Contact ___________________________Tel.____________________

IMPORTANT NOTICES – PLEASE READ EVERYTHING & FOLLOW INSTRUCTIONS:

1. We sometimes list students’ names (first name/last initial only) and pictures (without names) on our website (www.RoInslerTKD.com) and in newsletters when welcoming new students, announcing birthdays (month/day only), or when listing accomplishments in training or participation in certain events. Please indicate your permission or refusal to use your name or pictures by checking the appropriate box below and signing on the space provided.

* PLEASE DO NOT INCLUDE MY NAME OR PICTURES ON WEBSITE/NEWSLETTERS X ____________________________

* I GRANT PERMISSION TO USE MY NAME/PICTURES ON WEBSITE/NEWSLETTERS X ________________________________

2. Any and all documents, papers and forms distributed in class must always be read, and any and all requested forms (including this one) should be signed and returned when necessary.

3. Respectfulness and attentiveness is required at all times as they are the keys to success in training and in safety. Participants should abide by all of the rules and regulations as set forth by Ro Insler Taekwondo and its staff, including those regarding proper conduct and behavior.

4. A physician’s approval should be obtained before enrolling in any martial arts program, especially if the participant has had a recent illness or injury or has never participated in a physical exercise program or contact sport.

5. Medical conditions, especially if requiring medications and/or physical limitations, must be brought to Ro Insler Taekwondo’s attention immediately. In some cases, a physician’s authorization to participate may be required. Such information shall be kept strictly confidential, known only to Ro Insler Taekwondo’s instructors and staff, and only if it is absolutely necessary for your safety or benefit

PLEASE READ BOTH SIDES AND SIGN WHERE INDICATED TO FACILITATE PARTICIPATION

RO INSLER TAEKWONDO

> > > > > STUDENT PARTICIPATION & RELEASE FORM < < < < <

This page must be read in entirety and signed by the Participant (or Parent/Guardian if under the age of 18).

Place check marks at each paragraph “bubble” to indicate you have read the contents.

I/We understand and acknowledge that I/we have been hereby advised of the following:

o Participants must adhere to all instructions and directions given by the instructors and assistants, either verbally or in written form. All instructions, directions, rules and precautions are important for the safety of every participant. FAILURE TO ABIDE BY THOSE INSTRUCTIONS, DIRECTIONS, RULES AND PRECAUTIONS MAY RESULT IN DENIAL OF PARTICIPATION AND/OR POSSIBLE EXPULSION.

o This is a physical and aggressive, contact sport. Although the instructors take every precaution for students’ safety, there are certain risks and dangers associated with participation in martial arts events and activities which could result in bodily injury, partial and/or total disability, paralysis and, in extreme cases, even death. These risks and dangers may be caused by the action, inaction or negligence of the participant or the action, inaction or negligence of others, including, but not limited to, the Releasees named below. There may also be other risks not known to me/us or that are not reasonably foreseeable at this time.

o Participants have the right to inspect the facilities and equipment to be used, and if he/she believes anything is unsafe, should immediately advise the officials of such condition and refuse to participate.  I/we understand and agree that, if at any time, I/we feel anything to be unsafe; I/we will immediately take all precautions to avoid the unsafe area and refuse to participate further.

o Participants accept and assume such risks and responsibility for the losses and/or damages following such injury, disability, paralysis or death, however caused and whether caused in whole or in part by the negligence of the Releasees named below.

o I/We HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the martial arts facility used by the participant, including its owners, managers, promoters, lessees of premises used to conduct the martial arts event or program, premises and event inspectors, underwriters, consultants and others who give recommendations, directions or instructions to engage in risk evaluation or loss control activities regarding the martial arts facility or events held at such facility and each of them, their directors, officers, agents, employees, all for the purpose herein referred to as “Releasees”…from all liability to the undersigned, my/our personal representatives, assigns, executors, heirs and next to kin For any and all claims, demands, losses or damages and any claims or demands therefore on account of any injury, including but not limited to the death of the participant or damage to property, arising out of or relating to the events(s) caused alleged to be caused in whole or in part by the negligence of the Releasees or otherwise.

o I/We HEREBY acknowledge that THE ACTIVITIES OF THE EVENT(S) ARE DANGEROUS and may involve the risk of serious injury and/or death and/or property damage.  Each of THE UNDERSIGNED also expressly acknowledges that INJURIES RECEIVED MAY BE COMPOUNDED OR INCREASED BY NEGLIGENT RESCUE OPERATIONS OR PROCEDURES OF THE RELEASEES.

o EACH OF THE UNDERSIGNED further expressly agrees that the foregoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as is permitted by the law of the Province or State in which the program is conducted and that if any portion is held invalid, it is agreed that the balance shall, notwithstanding continue in full legal force and effect.

o On behalf of the participant and individually, the undersigned participant(s), parent(s) and/or legal guardian(s) for the minor participant(s) executes this Waiver and Release.  If, despite the release, the participant makes a claim against any of the Releasees, the parents(s) and/or legal guardian(s) will reimburse the Releasee for any money which they have paid to the participant, or on his behalf, and hold them harmless.

BY SIGNING THIS DOCUMENT I/WE HEREBY STATE THAT I/WE HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I/WE HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WTHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME /US AND INTEND MY/OUR SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.

_________________________/___________ _______________________________________________ __________

Participant’s printed Name / Date of Birth Participant’s Signature (or Parent’s/Guardian’s if age 17 & under) Date

Martial Arts School: ROSEANNE M. INSLER, d/b/a RO INSLER TAEKWONDO ______________________________