United States Kido Federation

Member Name (required)

Email Address (required)

Telephone Number (required)

Full Address: Number, Street, City, State, Zip Code (required)

Date of Birth YYYY-MM-DD (required)

What style of Korean martial arts do you practice (required)
TaeKwon-DoHapkidoTang Soo DoOther Korean Art

What is your Current Rank (required)
Gup (under Black Belt)Black Belt 1st – 3rd DanBlack Belt 4th – 6th DanBlack Belt 7th – 9th Dan

School Name

Instructor Name and Contact Information

MEDICAL RELEASE: I understand that in the event the student listed above is significantly injured, ill, unconscious, and/or no one otherwise authorized to contact Emergency Medical Service (EMS) personnel is present; it will be the practice of the instructor(s) to contact EMS personnel on behalf of the student. I give my permission for responding EMS and hospital personnel to begin necessary treatment. Furthermore, I agree to be financially responsible for any and all medical treatment for student listed herein. Adult Student or Adult Guardian Electronic Signature Below

INFORMED CONSENT, LIABILITY WAIVER, RELEASE, AND INDEMNIFICATION:

By signing this form I agree that I have been informed that I should not participate in any activity if I have any doubt or if I am uncertain as to my current medical condition. I understand that I should always seek medical advice before starting any physical training program. I understand that the activities in which I participate are physically and mentally intense and may require extreme exertion and give rise to the possibility of injury or death. I hereby certify that I am in good health and do not suffer from any heart condition or other ailment that could be exacerbated by the exertion involved in the activities in which I participate. I confirm and agree that I am fully aware of the risk and certify that I (my child/legal ward) am physically able to participate in this organization’s activities. I further agree that I will comply with all the rules, regulations, and instructions given to me by any federation instructor, assistant instructor, or corporation official.

Further, I (on behalf of my heirs, personal representatives, executor, and administrator) hereby waive, release, remise, indemnify for any and all claims, covenant not to sue and forever discharge from any claims and liabilities whatsoever without limitations that I have which arise against Five Elements Massage, Martial Arts, and Oriental Health Center, LLC – the United States Kido Federation or any owner, operator, official, supervisor, officer, participant, agent, instructor, agent, judge, volunteer, sanctioning entity, or employee from any expense, damage, loss, injury, or liability (including attorney fees) due to my decision to participate in a school martial arts class, tournament, or seminar. I agree to indemnify and hold harmless the above mentioned entities for any and all loss, injury, damage, claim, and liability. I confirm that I either have specific insurance to cover any injuries that I may sustain or that I have chosen to participate in these activities without any insurance coverage and agree to assume full responsibility of risk and bodily injury, death, and property damage. I hereby assume any and all risks, known and unknown, which may arise from my decision to participate in this activity. I agree to allow Five Elements Massage, Martial Arts, and Oriental Health Center, LLC – the United States Kido Federation to utilize any photograph, or audiovisual recording taken of me or my child at any class or event to promote the program. I understand that I will not be compensated in any way for use by the program.

I hereby certify that I am at least 19 years of age. If I am not at least 19 years of age, the signature of my parent(s) and/or legal guardian (s) must appear in the box below.

If member is under 18, insert parent/guardian contact information. Name, Address, Telephone Number