Student Release and Waiver

	Arizona Shaolin Kenpo Academy
	Student Release and Waiver

Name: ______________________________________________ Birth date: ____________________________________
Last First Middle

Address: _______________________________________________________________________ Home Phone: _________________________________

City/State/Zip ________________________________________ Work Phone: __________________________________

I understand that martial art is a contact sport as such, I am aware that I am participating in an activity which involves physical contact and that injuries may occur, which may potentially involve great bodily harm or even death, and I do so at my own rick. I the unsigned, do voluntarily summit my application for attendance in Kenpo, Tai Chi, Grappling, Kick boxing, Weapons, Self defense , instructions and activities related to instructions learned during any Arizona Shaolin Kenpo Academy classes. I state that I do not suffer from any physical and/or mental condition which may affect my participation in this type of activity.

I do hereby assume full responsibility for any and all damages, injuries, and/or losses that I may sustain or incur, if any, while attending or participating in any activities sponsored wholly or in part by Arizona Shaolin Kenpo Academy classes. I hereby waiver all claims against the instructor, his promoters, operators, assistants, or sponsors of any of the above activities, for any claim for injuries that I may sustain. I fully understand that medical treatment given to me, if any, will be of first aid treatment type only. For purposes of sparring, I understand that there are different levels of contact, and that I can include contact to the groin, neck, or head, including the face. All participants are expected to show control and restraint in regards to the power level involved.

I also understand that for sparring purposes, the following equipment is required: mouth guard, shin and instep pads, foam hand gear, foam feet protective gear ( for advanced sparring which includes contact to the face and protective head gear ), cup and supporter, and protective head gear. Optional equipment is strongly suggested such as chest protectors and forearm pads.

I further consent that any pictures furnished by me or any pictures taken of me in connection with Arizona Shaolin Kenpo Academy activities can be used for publicity , promotion, or television showing, and I waive compensation in regard thereto.

If under 18, this Release and Waiver form also must be signed by a parent or guardian.

Signature of student Parent or Guardian (if student is under 18).

_______________________________ _____________________________

Date: ___________

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