Application, Registration & Release Form
for practice and training with
SAKURA DOJO LLC.
Name: / Date of Birth:Race: / Sex:
Address:
City: / State, ZIP:
Home Phone: / Mobile:
E-mail:
In Case of Emergency-Contact:
Relationship:
Prior Experience in Recreational Arts:
Other Relevant Experience:
Special Information (Allergies, limiting or relevant injuries, medical conditions, medications, physician, etc.):
PLEASE READ THE FOLLOWING CAREFULLY. YOU ARE BEING ASKED TO RELEASE ALL LIABILITY.
I, the undersigned, acknowledge that I am applying for instruction in self-defense and Aikido a martial art, Aikijutsu, Yoga, PreNatal Yoga, Pilates, Tai Chi, Win Chun, KickBoxing Fit (KBF), Kick Boxing, Thai Boxing, Dancing (all kinds of dancing including belly dancing), Gymnastics and Muscle Coordination, Kids Aikido, Summer Camps (including Horse back Riding and outdoor activities of all kind) involving strenuous exercise and personal body contact. This may include limitation, being grabbed, pushed, punched, kicked, struck with weapons, being thrown to the ground, falling to the ground and possible exposure to blood. I understand that because of this there is always an inherent risk to injury that can not be eliminated. Such injuries may include; but are not limited to, pulled muscles, dislocated joints, broken teeth, broken bones, twisted ankles, and even possibly death. I acknowledge that Sakura Dojo LLC. , Yaman Gedikoglu and its instructors, students, agents, officers, or directors carry no insurance against injury to any of its students. I have or realize I should have my own medical insurance and my own life insurance to cover any situation that could occur.
I also realize that I may at any time refuse to engage in any activity that I deem harmful to myself in any way, and by engaging in any of the activities of Sakura Dojo LLC. I fully accept and acknowledge all risks involved. I AM ASSUMING ALL LIABILITY AND RISKS!
In consideration for being admitted into Sakura Dojo LLC. and receiving training in self-defense and Aikido, Aikijutsu, Yoga, PreNatal Yoga, Pilates, Tai Chi, Win Chun, Kick Boxing Fit (KBF), Kick boxing, Thai Boxing, Dancing (all kinds of dancing including belly dancing), Gymnastics and Muscle Coordination, Kids Aikido, Summer Camps (including Horse back Riding and outdoor activities of all kind) consideration that I hereby acknowledge is valuable and adequate to support my performance under this contract of release, I agree to hold Sakura Dojo LLC., Yaman Gedikoglu, it's instructors, students, agents, officers or directors harmless from all liability that arises, directly or indirectly, from injury to me or from injury caused to third parties by me, while a student of Sakura Dojo LLC. Or elsewhere, and at any time in the future. I agree not to sue Sakura Dojo LLC., Yaman Gedikoglu, its instructors, students, agents, officers, or directors and agree to reimburse Sakura Dojo LLC., Yaman Gedikoglu, its instructors, students, agents, officers or directors, for all attorney fees and all costs if I do sue.
Blood Related Matters
It is very possible that at some point in your training at Sakura Dojo LLC, you will on some occasion, knowingly or otherwise, practice with students who are HIV positive. You also may be exposed to bleeding or blood in the training area. There is no way to predict, or entirely prevent this. With a little common sense there is also no reason to be anxious since all current research affirms that contact sports provide no risk to the practitioners where blood is not a factor.
However, since the only means of transmission of the virus at all relevant to training concerns the presence of blood, the following POLICY should be strictly observed:
Treat any and all blood in Sakura Dojo LLC with utmost caution. Blood on the mat(s) should be washed off immediately. Sakura Dojo LLC has appropriate gloves and bleach for this purpose. Also in the unlikely event that someone is injured enough to need help and is bleeding profusely, use gloves if there is any possibility when coming into contact with blood.
Much more likely are small abrasions or scrapes, and it is requested that you to keep your finger and toe nails clipped short to avoid cutting those you are working with. It is each students responsibility to COVER all open wounds or cuts. If such an injury occurs during class, discontinue training and attend to cover it. This makes good sense anyway.
I also agree that I have advised the instructor(s) of any existing and per-existing medical conditions. - mental and physical, any existing and per-existing injuries, or other existing and per-existing conditions that may affect my participation at Sakura Dojo LLC. I have also acknowledged that I am in good physical condition and my medical doctor(s) have approved of my participation of physical activities at Sakura Dojo LLC. I am responsible from my health and safety at Sakura Dojo LLC and do not and will not hold Sakura Dojo LLC or anyone else responsible for my well being.
Above all, use common sense!
I have read the above section on blood related matters and specifically acknowledge and accept all risks that may be implied in the practice and training conducted at Sakura Dojo LLC. I am familiar with the procedures to be followed should there be exposure to blood while a student of Sakura Dojo LLC and agree to follow those procedures as best as reason and common sense will allow.
I certify that I have read the foregoing contract, that I understand it's terms, that I have no physical infirmities that would be aggravated by the activities described in this contract, that I am 18 years of age or older, that no one has made any representations to me that in any way contradict with the terms of this contract, and that I am signing this contract of my own free will.
I understand that Sakura Dojo LLC is an educational system. For the benefit of this education, training, and the safety of the other members, instructors, and myself, I will strictly follow the procedures, regulations, requirements, dues and fees schedules. I understand all of the procedures, regulations, fee schedule, training rules, and other areas.
I also hereby agree to abide by the Sakura Dojo LLC procedures, regulations, fee schedule, training rules and other areas. Should I break any of these rules or by-laws, I understand that it is the decision of the Chief Instructor whether or not I may continue training. I will abide by his or her decision.
In addition, Sakura Dojo LLC, Yaman Gedikoglu, its instructors, students, agents, officers, or directors are not responsible for any personal items or property. I must safeguard and secure any personal items or property.
Signature:Date:
If the applicant is under 18:
I, the undersigned, as parent or guardian of the above applicant, certify that I have read the above contract and I also consent to the applicant's receiving the instruction applied for and I agree to the provisions of the contract for myself and said applicant.
Relation to applicant:Signature:Date: