Wilderness Martial Arts Registration and Contract

First Name: ___________________________ Last Name: _______________________________

Age: _____ Date of Birth: ___/___/_____ School Attending:_____________________________
To Be Completed By Student And / Or Parent / Guardian - If Under Age 21
Student and / or Guardian Name:
First Name: ___________________________ Last Name: _______________________________
Phone :
Home: ________________ Cell: _________________ Work: _________________
Driver
s License Number: State ______ #______________________________ Address:
_____________________________ City: ______________________ State and
Zip:_________________________

Wilderness Martial Arts Instruction Waiver and Release of Liability

I do hereby agree to participate in Wilderness Martial Arts (referred to as
Company
) located
in Virginia Beach, VA. The responsible party must read the entire contract before signing.
Before beginning any type of martial arts training or any kind of exercise program, you should
first consult your physician. While training, serious injuries are possible, including sprains, strains,
twists, cramps, and other injuries of similar magnitude. Individuals training in the martial arts
can expect to encounter these injuries infrequently. The possibility of more serious injury exists,
including fractured bones, broken bones, and torn ligaments, though not all martial artists
encounter such serious injuries. As with any martial arts training or physical activity, there also
exists the remote possibility of crippling or death.
While training for the outdoor environment, there is also the risk of serious injuries, including
hypo- and hyperthermia, dehydration, bites from insects and animals, exposure to toxic plants,
burns, falls, sprains, strains, cramps, and other injuries of similar magnitude. The possibility of
more serious injuries exist, including deep lacerations, broken bones, fractured bones, and torn
ligaments, although not all who take part in the outdoor environment experience such serious
injuries. Due to unpredictability of the outdoor there exists the possibility of debilitating injury or
death. During any martial arts training or exercise if you feel dizzy or faint or experience any pain
whatsoever, you must stop immediately and without delay seek the advice of a physician or
heaIn consideration of being allowed to participate in any way in Wilderness Martial Arts
instruction or training, and related events and activities, the undersigned:
1. Agrees that prior to participating, they will inspect the facilities used and equipment to be
used, and if they believe anything is unsafe, they will immediately advise their instructor, coach
or supervisor or facility personnel of such condition(s) and refuse to participate.
2. Acknowledges and fully understand that they will be engaging in activities that involve risk of
serious injury, including permanent disability and death, and severe social and economic losses
which might result not only from their own actions, inactions or negligence but the actions,

inactions or negligence of others, the rules of training, or the condition of the premises or of any
equipment used. Further, that there may be other risks not known or not reasonably foreseeable
at this time.
3. Assumes all the foregoing risks and accepts personal responsibility for the damages following
such injury, permanent disability or death.
4. Releases, waives, discharges and covenants not to litigate/sue the instructor(s), affiliated
clubs, regional sports organizations, their respective administrators, directors, agents, coaches,
and other employees of the organization, other participants, sponsoring agencies, sponsors,
advertisers, and, if applicable, owners and leasers of premises used to conduct the instruction, all
of which are hereinafter referred to as "release
s" from any and all liability to each of the
undersigned, his or her heirs and next of kin for any and all claims, demands, losses or damages
on account of injury including death or damage to property, caused or alleged to be caused in
whole or in part by the negligence of the release
s or otherwise
5. Agrees that all movements learned will be used for self-defense and self-preservation
purposes only, and only as a last resort.
The undersigned has read and fully understands the above Waiver and Release. I hereby
execute this Waiver and Release form permitting my minor child and / or myself to participate
in the Company
s program
I understand that monthly tuition of $50.00 is due and must be paid on or before the 1st of each
month, regardless of Student
s absence, major holidays, and / or school holidays. Testing fees (if
eligible) must be paid at prior to testing. I understand that I will not receive a courtesy reminder,
and that tuition not received by the first of each month will not be allowed to train. Students
will receive a notice for testing fees on the 1st of the month if eligible. Be advised that it must be
received on time. All fees are subject to an annual increase due to the cost of living.
I understand that tuition, camps, testing fees and private lessons are non-refundable. I
understand that if I wish to terminate membership I will not be refunded any portion of the
tuition paid.
Tuition will cover instruction, testing up to brown belt, first uniform, and school patches.
Additional uniforms, additional patches, equipment, camps, testing fees, private lessons, etc.
are all additional costs and are not included in with tuition or registration. We do ask that
students come to class dressed and remain seated or line up in designated area prior to their
scheduled class. Parents and family members are welcome to watch classes, but must be quiet
and not disturb the students or staff.
By signing below indicates that you have read the Waiver and Release guidelines, terms and
conditions, and regulations on this contract and fully understand the contents. This contract will
remain on file in the Karate office unless the terms and conditions change. At that time a new
contract will be executed.
I have executed this Waiver and Release this ______ day of _______, 20______.
___________________________________________________
Signature of Student or Parent / Guardian if under the age of 21
___________________________________________________
Printed Name of Student