Fill out this form or call to attend

one week of free trial classes

Name

First Name

Last Name

Phone

(###)

###

####

Email Address

Checkbox

By clicking this check box I agree to the below liability waiver listed on the Genbukan Umineko Dojo website. A PDF version of the Liability Waiver is also posted at the below link.

Release of Liability & Waiver of Legal Rights and Assumption of Risk

Release of Liability & Waiver of Legal Rights and Assumption of Risk and Honbu Dojo Visitor Agreement PDF File

In consideration of the services by Umineko Dojo, LLC, their owners, agents, officers, participants, employees, and all other persons/entities, and ranges acting in any capacity on their behalf (hereafter collectively referred to as “UD”, I hereby understand and agree to discharge UD on behalf of myself, my children, my parents, my heirs, assigns, personal representative and estate as follows: 1. I acknowledge that learning self-defense entails known and unanticipated risks which could result in physical or emotional injury, paralysis, or damage to myself, to property, or to third parties, up to and including death. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. UD employees are consummate professionals and experts in their respective fields. However, due to the inherent risks of martial arts and learning self-defense, situational circumstances may occur with unintended consequences up to and including serious bodily injury and/or death. 2. I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks. 3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless UD from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or use of UD equipment or facilities used by UD, including any such Claims which allege negligent acts or omissions of UD. 4. I release and hold harmless UD from all liability, claims, judgments, costs including attorney’s fees, demands or causes of action that I may hereafter have for injuries or civil damages arising out of my participation in UD services/courses. I agree to indemnify and hold UD harmless for all such fees and costs. 5. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I have no medical or physical conditions, which could interfere with my safety in this activity, or else I am willing to assume – and bear the cost of – all risks that may be created, directly or indirectly, by any such condition. I certify that I am physically fit, have sufficiently prepared or trained for participation in the activity or event, and have not been advised to not participate by a qualified medical professional. 6. I hereby consent to receive medical treatment (to the extent of minor first-aid and to the level of medical training which the instructors currently hold) which may be advisable in the event of injury, accident, and/or illness during this activity or event. I understand that if there is a medical emergency outside the realm of minor first-aid the instructors will request emergency assistance. 7. As a condition of participation UD services I agree not to use the information and techniques that are shared in a Course for any purpose that is unlawful, illegal, unethical or any improper or objectionable purpose. I agree not to impersonate any other law enforcement person or entity, by words or actions, whether actual or fictitious. I agree to not act with intent to induce another to submit to such pretended official authority. I agree that the information shared in a Course does not give me authority over active and official law enforcement officers in any capacity nor does it make me a law enforcement officer in any capacity. I agree to comply with any applicable local, state, federal laws regarding self-defense and am advised to seek and consult with an attorney if presented with any situation which has resulted in criminal charges and/or civil litigation against me. 8. I agree that prior to participating in a Course, I may inspect the facilities and equipment to be used, and if I believe anything is unsafe, I will immediately advise the instructors of such condition and refuse to participate. I agree that I may REFUSE to participate in any activity that I feel in unsafe. I understand and agree that, if at any time, I feel anything to be UNSAFE, I will immediately take all precautions to avoid the unsafe area or activity and REFUSE TO PARTICIPATE further. 9. I understand that I may be photographed or videotaped. I agree to allow my image and likeness in the form of photo, video, whether digital/electronic or film, to be used for any legitimate and legal purpose in the media of print publication or internet, without compensation, to UD. I agree to waive all rights to inspect and approve the images and that the images will be used without notifying me. The images, if used, will be used with respect and consideration. I have read this release of liability, waiver of legal rights and assumption of risk and fully understand its contents. I represent that I am of legal adult age and I sign this document and participate in spite of the risks of my own free will. This release of liability, waiver of legal rights and assumption of risk shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I HAVE HAD SUFFICIENT OPPORTUNITY TO READ THIS ENTIRE DOCUMENT. I HAVE READ AND UNDERSTOOD IT, AND I AGREE TO BE BOUND BY ITS TERMS.

Honbu Dojo Visitor Agreement

I will watch or take part in a trial class. Through the duration of the class I agree to the following: I will follow any instruction given to me by the teacher. I acknowledge that I am not necessarily covered by this dojo's insurance, in the case of any accidents, injuries or other problems. I will not sue or make any claim against this organization, this dojo, the teacher, or any other student, who is participating. I will not take photos/memos or otherwise record the details of this class, without the permission of the teacher. Furthermore, I promise that I will not use or teach any techniques, which I have seen or learned during the class, except in the case of a real emergency.