REGISTRATION FORM

REGISTRATION FORM Kodama Dojo seminar 2008

Name: _________________________ Age & Date of Birth:___________________ Sex: M F

Address:____________________________________________________

_____________________________________________________

E-mail address:_____________________________

Phone #'s: Cell_________________ Home__________________ FAX__________________

Emergency phone number & name of person to contact: ________________________________

Home Dojo & Dojo Cho (lead Instructor):___________________________________________

Your rank:_________________

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I will be participating in:

Full Seminar____ $90 ($80 if paid before April 1, 2008)

Friday only_____ $45

Saturday only____ $50 - $45 for one session

Sunday only____ $45

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Submit payment by check along with signed Release and Waiver of Liability to:

Bob Whaley c/o Kodama Dojo

519 Oak Bridge Dr.

Ballwin, Mo. 63021

*Call 314-378-5241 for further information

Release and Waiver of Liability and Indemnity Agreement

(Read Carefully Before Signing)

In consideration of being permitted to participate in any way in the Martial Arts Program indicated below and/or being permitted to enter for any purpose any restricted area (here in defined as any area where in admittance to the general public is prohibited), the participant or parent(s) and/or legal guardian(s) of the minor participant named below agree:

1. The participant agrees (or parent(s) and/or legal guardian(s) will instruct the minor participant) that prior to participating in the below martial arts activity or event, he or she should inspect the facilities and equipment to be used, and if he or she believes anything is unsafe, the participant should immediately advise the officials of such condition and refuse to participate. I understand and agree that, if at any time, I feel anything to be UNSAFE; I will immediately take all precautions to avoid the unsafe area and REFUSE TO PARTICIPATE further.

2. I/We fully understand and acknowledge that:

a. There are 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 death.

b. The social and economic losses and/or damages, which could result from these risks and dangers described above, could be severe.

c. 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.

d. There may be other risks not known to us or are not reasonably foreseeable at this time.

3. I/WE 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.

4. I/We HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the martial arts facility used by the participant, including it 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 “Releasee”…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 releasee or otherwise.

5. I/We HEREBY acknowledge that THE ACTIVITIES OF THE EVENT(S) ARE VERY DANGEROUS and 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.

6. 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 event 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.

7. The participant (or on behalf of the participant and individually, the undersigned partners(s) and/or legal guardian(s) for the minor participant) 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.

I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I 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 AND INTEND MY SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.

Martial Arts School ______________________________________________________

Student Signature __________________ ____________________________________

Parent or Guardian Signature (if minor) ____________________________________

Printed Name of Participant _______________________________________________

Address of Participant ____________________________________________________

Received by _____________________________________________________________

Registrar Signature Printed Name Date