summer camp waiver and release of liability€¦ · american kenpo karate academy . 10391 central...

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Page 1: Summer Camp Waiver and Release of Liability€¦ · American Kenpo Karate Academy . 10391 Central Park Drive . Manassas, VA 20110 . 703-335-6770 . Summer Camp Waiver and Release of

American Kenpo Karate Academy 10391 Central Park Drive Manassas, VA 20110 703-335-6770

Summer Camp Waiver and Release of Liability

Please Print Clearly Participant/Child’s Name:_______________________________________________________________ Parent/Guardian: _____________________________________________________________________ Address: ____________________________________________________________________________ City, State, Zip: _______________________________________________________________________ Home Phone #: _______________________________________________________________________ Email:_______________________________________________________________________________ Parents/Guardian of Minor must complete and sign the Waiver and Release below in order to allow their child to participate. I,_________________________________________, the undersigned do voluntarily allow my Child ________________________ to attend camp on these Dates________________________ at American Kenpo Karate Academy. The undersigned agrees that they are aware that their Child is engaging in physical exercise possibly including the use of exercise equipment, training and instruction which could cause injury. The School urges all students obtain a physical examination from a doctor before using any exercise equipment or participating in any exercise class. All exercises, including the use of any and all equipment and apparatus designed for exercising shall be at the student, Parent/Guardian’s entire responsibility, and American Kenpo Karate Academy shall not be liable to student Parent/Guardian for any claims, demands, injuries, damages or actions arising due to injury to student’s person or property arising out of or in connection with the use by student of the services, facilities, and premises of American Kenpo Karate Academy. The Student, Parent/Guardian hereby holds American Kenpo Karate Academy, its officers, owners, agents and employees, harmless from all claims which may be brought against them by student, parent/Guardian or on student’s behalf for any such injuries or claims. Parent or Guardian, Name:____________________________________________ Signature:___________________________________________ Date:_____________________