1
ENCINITAS KARATE Permission Slip for Guests DUE TO INSURANCE REQUIREMENTS, GUESTS WILL NOT BE ADMITTED TO ANY EVENT WITHOUT A FULLY COMPLETED AND SIGNED PERMISSION SLIP. We do not share your information with anyone. Parent/Guardian Info: Name: Phone # (Required in the event of an emergency) E-mail : Guest/Minor Info: Name: Age: Bate of Birth: Male Female Applicant/undersigned agrees to indemnify and hold harmless Encinitas Ka- rate Inc., it’s officers, directors, volunteers, officials, staff and contractors from any and all liability, losses or damages whatsoever, including emotional distress, arising from participation in any of their programs. In case of an accident or other emergency, personnel/officers/directors of Encinitas Karate Inc. are hereby authorized to secure medical care deemed necessary as a result of accident or injury for the participant. I further agree to pay any and all costs incurred as a result of this treatment. I hereby irrevocably consent to and authorize the use and reproduction of photographs and video taping of any Encinitas Karate Inc, event for promo- tional use or for the Dojo’s web-site. Such footage may be used in any manner deemed appropriate by Encinitas Karate Inc. without compensation. Parent/Guardian Signature Date: ENCINITAS KARATE Permission Slip for Guests DUE TO INSURANCE REQUIREMENTS, GUESTS WILL NOT BE ADMITTED TO ANY EVENT WITHOUT A FULLY COMPLETED AND SIGNED PERMISSION SLIP. We do not share your information with anyone. Parent/Guardian Info: Name: Phone # (Required in the event of an emergency) E-mail : Guest/Minor Info: Name: Age: Bate of Birth: Male Female Applicant/undersigned agrees to indemnify and hold harmless Encinitas Ka- rate Inc., it’s officers, directors, volunteers, officials, staff and contractors from any and all liability, losses or damages whatsoever, including emotional distress, arising from participation in any of their programs. In case of an accident or other emergency, personnel/officers/directors of Encinitas Karate Inc. are hereby authorized to secure medical care deemed necessary as a result of accident or injury for the participant. I further agree to pay any and all costs incurred as a result of this treatment. I hereby irrevocably consent to and authorize the use and reproduction of photographs and video taping of any Encinitas Karate Inc, event for promo- tional use or for the Dojo’s web-site. Such footage may be used in any manner deemed appropriate by Encinitas Karate Inc. without compensation. Parent/Guardian Signature Date:

ENCINITAS KARATE ENCINITAS KARATE

Embed Size (px)

Citation preview

ENCINITAS KARATE Permission Slip for Guests

DUE TO INSURANCE REQUIREMENTS, GUESTS WILL NOT BE ADMITTED TO ANY EVENT WITHOUT A FULLY COMPLETED AND SIGNED PERMISSION SLIP. We do not share your information with anyone.

Parent/Guardian Info:

Name:

Phone # (Required in the event of an emergency)

E-mail :

Guest/Minor Info:

Name:

Age: Bate of Birth: □ Male □ Female

Applicant/undersigned agrees to indemnify and hold harmless Encinitas Ka-rate   Inc.,   it’s   officers,   directors,   volunteers,   officials,   staff   and   contractors from any and all liability, losses or damages whatsoever, including emotional distress, arising from participation in any of their programs. In case of an accident or other emergency, personnel/officers/directors of Encinitas Karate Inc. are hereby authorized to secure medical care deemed necessary as a result of accident or injury for the participant. I further agree to pay any and all costs incurred as a result of this treatment. I hereby irrevocably consent to and authorize the use and reproduction of photographs and video taping of any Encinitas Karate Inc, event for promo-tional  use  or  for  the  Dojo’s  web-site. Such footage may be used in any manner deemed appropriate by Encinitas Karate Inc. without compensation.

Parent/Guardian Signature Date:

ENCINITAS KARATE Permission Slip for Guests

DUE TO INSURANCE REQUIREMENTS, GUESTS WILL NOT BE ADMITTED TO ANY EVENT WITHOUT A FULLY COMPLETED AND SIGNED PERMISSION SLIP. We do not share your information with anyone.

Parent/Guardian Info:

Name:

Phone # (Required in the event of an emergency)

E-mail :

Guest/Minor Info:

Name:

Age: Bate of Birth: □ Male □ Female

Applicant/undersigned agrees to indemnify and hold harmless Encinitas Ka-rate   Inc.,   it’s   officers,   directors,   volunteers,   officials,   staff   and   contractors from any and all liability, losses or damages whatsoever, including emotional distress, arising from participation in any of their programs. In case of an accident or other emergency, personnel/officers/directors of Encinitas Karate Inc. are hereby authorized to secure medical care deemed necessary as a result of accident or injury for the participant. I further agree to pay any and all costs incurred as a result of this treatment. I hereby irrevocably consent to and authorize the use and reproduction of photographs and video taping of any Encinitas Karate Inc, event for promo-tional  use  or  for  the  Dojo’s  web-site. Such footage may be used in any manner deemed appropriate by Encinitas Karate Inc. without compensation.

Parent/Guardian Signature Date: