Application and Consent Form

2017-2018 YK SHINTANI WADO KAI KARATE CLUB

APPLICATION AND CONSENT FORM

Name: ______Phone: ______Date of Application:______

Full Address: ______Email:______

Date of Birth: Year: _____ Month: _____ Day: _____ Age: _____ Gender (M/F):______

Have you previously studied martial arts? Yes: _____ No: _____

If yes, indicate when: ______Where: ______

Style: ______Rank Attained: ______Instructor:______

The word CLUB shall include the Yellowknife Shintani Wado Kai Karate Club.

The word Federation shall include the Shintani Wado Kai Karate Federation.

In consideration of acceptance of my application for membership, I hereby release and forever discharge the CLUB, the Federationand Patrick Fred Clancy, its officers, instructors, members, authorized guests and any persons or organization howsoever connected with the CLUB and Federation fromany liability of any nature or kind whatsoever arising out of or in any way connected with any and all legal or civil actions, causes of actions, lawsuits, claims and demands, for damages, monetary or otherwise, loss or injury, howsoever arising, which may hereafter be sustained by me in consequence of my membership or my participation connected with the CLUB or Federation activities. In particular, I agree that the CLUB, and the Federation, and its members and any persons or organization howsoever connected with the CLUB or Federation shall not be responsible for any loss or theft of my personal possessions while using the CLUB’s premises and/or facilities. I have carefully read the above conditions and hereby fully understand and agree to, and will comply with all of them.

The Head Instructor of the CLUB reserves the right to deny membership into the CLUB. The Head Instructor also reserves the right to dismiss any club member from the club, at any time, if the Head Instructor determines a members behavior or deportment to be unsuitable to the CLUB’s standards for behavior, is deemed to be disrespectful to the Head Instructor or any member of the CLUB, or is deemed to be contrary or detrimental to the CLUB’s goals and objectives. The applicant agrees to allow the CLUB to use any photograph, digital or otherwise, that may be taken of the applicant while training, or during activities in the CLUB dojo, or of official or unofficial functions relating to the CLUB. The applicant also agrees to allow the CLUB to use any photo or likeness of the applicant in the advertising of Club activities and functions while they are members of the club,or after the applicant terminates membership in the Club.

Dated at : ______(Town or City), this day of ______(day/month/year).

Signature of Applicant: ______

Signature of Witness: ______

If under 18 years of age, please fill out below:

I hereby consent to the above application and in consideration of the acceptance of the application, I hereby agree to indemnify and save harmless the CLUB, the Federationand Patrick Fred Clancy, its officers, instructors, members, authorized guests and any persons or organization howsoever connected with the CLUB or Federation from any liability of any nature or kind whatsoever arising out of or in any way connected with all legal or civil actions,lawsuits, claims or demands for damages, monetary or otherwise, loss or injury made by or on behalf of the applicant and I hereby consent and agree, on my behalf and the applicant’s behalf, to the terms of the application for membership signed by the applicant.

Dated at: ______(Town or City), this day of ______(day/month/year).

Signature of Parent or Guardian: ______

The above application is hereby accepted by: ______

YK 2017-18 Karate Application & Consent Form