2016 Riverview Sports Camp
MARTIAL ARTS
JULY 4 - JULY 8, 2016
**REGISTRATION DUE BY: June 17, 2016**
Name:______Male ( )Female ( )
DOB:______Phone:______
E-Mail (required for receipt):______
T-Shirt Size: Adult ( ) Child ( )SIZE:______
RELEASE AND ARBITRATION AGREEMENT-RIVERVIEW SPORTS CAMP
ARRIVAL: 07/4/15 2:00PMDEPARTURE: 07/8/15 11:00AM
In consideration of RIVERVIEW BIBLE CAMP, I for myself, or the minor child named below, forever waive, release and discharge RIVERVIEW BIBLE CAMP (and its parent corporation) from any/all injuries, claims, disputes, liabilities, or actions resulting from RIVERVIEW BIBLE CAMP providing services for me and for my benefit regardless of location for the dates identified above, except for injury or damage arising out of RIVERVIEW BIBLE CAMP’S, negligence or willful misconduct. I attest and verify that I have full knowledge of the risks and dangers involved; that I assume such risks, and that I will assume and pay my own medical and emergency expenses, in the event of an accident, illness or other incapacity, regardless of whether I have authorized such expenses.
Any controversy arising out of, connected to, or relating to any matters herein of the transactions between me and the above named parties or on behalf of the minor child named below, of this Release/Waiver, or the breach thereof, including but not limited to any claims of violations of Federal and/or State Law, as well as any common law claims shall be settled by arbitration through Christian Conciliation Services; and in accordance with this paragraph a judgment based upon the arbitrator’s award may be entered in any court having jurisdiction thereof in accordance with the provisions of R.C.W.7.04. This agreement shall be construed and interpreted under the laws of the State of Washington. I HAVE READ THIS WAIVER AND RELEASE CAREFULLY, AND UNDERSTAND IT.
RELEASE INDEMNITY-ACADEMY OF SHOTOKAN MARTIAL ARTS
I, intending to be legally bound, do hereby release Rick Montgomery, staff and instructors, from any claims, liabilities, obligations, and causes of action or demands.
I, intending to be legally bound, do agree to indemnity said Rick Montgomery, staff and instructors, from any act committed during or arising out of or arising out of or as the result of any activity presented by Rick Montgomery.
I, further release Rick Montgomery, staff and instructors, from all claims of liability for any property or valuables lost, mislaid or stolen.
I give permission to Rick Montgomery, staff and instructors, to hospitalize and/or secure treatment for any medical issue or injury. This includes giving permission to exchange, written or orally, any information concerning any injury, illness, or medical history to medial personnel, as needed for emergency medical care.
I have read the foregoing and fully understand the contents of this release indemnity.
X
Print Participant’s NameBirthdate: MO/ DAY/ YEAR
X______Date:______
Signature (Parent/Guardian if participant named above is under 18)
In case of emergency notify:______Phone:______
Please list any pertinent medical history (example: asthma, heart, diabetic, allergies-including bee stings/food):
______
**Registration Worksheet**
KARATE TRAINING AND VACATION PACKET $400$______
Late Fee (if Applicable) $25$______
2016 Academy of Shotokan Martial Arts Members Discount$______
(Must be able to show proof with Membership Card)
Testing Fee (See below-membership discount does not apply to testing fee)$______
TOTAL DUE:$______
TESTING FEES
**All testing fees include the exam and the belt/certificate if exam passed**
Yellow Belt (8th Kyu)$35.00
Orange Belt (7th Kyu)$35.00
Green Belt (6th Kyu)$35.00
Blue Belt (5th Kyu)$55.00
Purple Belt (4th Kyu)$55.00
Brown Belt (3rd Kyu)$65.00
Brown Belt I Stripe (2nd Kyu)$65.00
Brown Belt II Stripes (1st Kyu)$65.00
Black Belt-Shodan (1st Degree)$135.00
Black Belt-Nidan (2nd Degree)$155.00
Amount Enclosed: $______
Registration Process:
Please send registration form and check/money order made out to:
Shihan Rick Montgomery
Address: 111 N. Adams Rd.
Spokane Valley, WA. 99216
**Once your check has cleared you will receive a receipt via e-mail**
Cancellation/Refund Policy:Our refund policy is: Only $200 of your payment is refundable if a request is received in writing prior to June 17, 2016. After June 17, 2016, the $200 refund will only be granted with a medical note signed by a physician. Refunds during camp secondary to injury, illness or any other issues will not be granted.
Returned Check Policy: If a check is returned for any reason, a $25.00 charge will be assessed. The camper will then not be allowed to participate until full CASH payment is received.
~~Directions to Riverview Bible Camp from Spokane, WA.~~
Head north on Division Street towards the "Y". Take the slight right turn onto US-2 E. Go 28.4 miles where you'll turn left onto WA-211 N. Go 15.2 miles and turn left onto State Route 20 W/WA-20 W. Go 12.7 miles and Riverview Bible Camp will be on your right.
RIVERVIEW BIBLE CAMP
408771 State Route 20
Cusick, WA. 99119