Martial Arts Classes - Student Records and Waiver Owen Johnston, Karate Instructor and Personal Trainer http

!!www"#ohnston$arate"co% &a%e ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' (ate o) *irth Address State '''''''''''''''''''''' ''''''''''''''''''''

'''''''''''''''''''''''''''''''' Cit+ ''''' ,ip '''''''''' -o%e Phone

''''''''''''''''''''''''' '''''''''''''''''''

Cell Phone Se/

'''''''''''''''''''' .-Mail Address

Male ''''' 0e%ale '''''

*+ si1nin1 this waiver o) clai%s and lia2ilit+, I ac$nowled1e that I have read this a1ree%ent and will a2ide 2+ all class rules set 2+ Owen Johnston, and a1ree to wear all %andator+ sa)et+ e3uip%ent" Si1nin1 this waiver also %eans that I release Owen Johnston )ro% an+ lia2ilit+ in the case o) in#ur+ as a result o) the instruction under Owen Johnston" I reco1ni4e that %artial arts and e/ercise carr+ so%e ris$ o) in#ur+ 5sprains, strains, 2ruises, di44iness, di))icult+ 2reathin1, heart attac$, 2leedin16, and that participation %a+ result in other da%a1e, due not onl+ to %+ actions, inaction or ne1li1ence, 2ut also to that o) others associated with and!or present at these activities" I personall+ assu%e all ris$s involved or in an+ wa+ related to %+ participation in these classes, whether $nown or un$nown to %e at the present ti%e" Participation is voluntar+ and entirel+ o) %+ own )ree will" I here2+ represent and certi)+ that I a% aware o) no %edical pro2le% 7 e/cept as noted on the provided health 3uestionnaire 7 that would increase ris$ o) illness and in#ur+ as a result o) participatin1 in an on1oin1 %artial arts or )itness pro1ra%" I) I do have an+ such conditions and would li$e to proceed with a %artial arts or )itness pro1ra%, I a1ree to o2tain %+ ph+sician8s consent 2e)ore doin1 so" I, %+ heirs, e/ecutors and successors here2+ waive all clai%s o) accidental and or ne1li1ent tort da%a1es or in#ur+ a1ainst Owen Johnston, and an+ ph+sical location where his classes are tau1ht" All records are $ept strictl+ con)idential" (ate '''''''''''''''''''''''''''''''''' 9our si1nature, or parent ! 1uardian si1nature 5i) +ou are under :;6 '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' Instructor si1nature '''''''''''''''''''''''''''''''''''''''''''''''