Activity: Martial Arts Training – JKA Shotokan Karate
Location: 10810 Wiles Road, Coral Springs, FL 33076

In consideration of being allowed to participate in any way in the above listed Activity, related events and activities,
I, the undersigned, on behalf of myself, my heirs, next of kin, successors and assigns, do knowingly, voluntarily and
intelligently, acknowledge, appreciate and agree that:

1. The risk of injury from the activities involved in the Activity is significant, including the potential for permanent
paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of
serious injury does exist; and
2. I, on my own behalf, or if for my minor child, and theirs, knowingly and freely assume all such risks, both known
and unknown, and assume full responsibility for my participation; and
3. I willingly agree to comply with the stated instructions and policies and customary terms and conditions for
participation. If, however, I observe any unusual significant hazard during my presence or participation, I will
remove myself from participation and bring such to the attention of the nearest official immediately; and
4. I understand that if I choose to drive my own vehicle or be a passenger in a vehicle operator by another to any
Activity venue, any Activity liability insurance coverage will not apply; and
5. I understand participation in this event may be of a hazardous nature and/or include physical and/or strenuous activity.
Understanding this, I state that I have no medical condition or impairment that might inhibit my safe and active
participation in the above listed activity. In addition, I understand that neither Shotokan Karate Center, Inc., the Japan
Karate Association – American Federation, nor the Japan Karate Association HQ (the “Covered Parties”), or any
venue used for any event associated with the Activity, provides medical insurance coverage for activity participants
and that any applicable medical insurance must be provided individually by such participants. In the case of injury or
medical emergency and in the event participant, or their parent or guardian, cannot respond at the time of the
emergency, participant agrees that any or all of the Covered Parties and their respective agents may, but have no duty
to do so, administer, or have administered whatever first aid or emergency medical care deemed necessary in their
sole and exclusive discretion for participant’s welfare, and it is understood that participant and all primary insured
under which participant may have insurance shall be solely and exclusively responsible for any and all charges for
such health care services regardless of whether participant’s medical insurance would cover such charges.
6. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release, indemnify
and hold the Covered Parties and their respective owners, officers, officials, agents, employees, volunteers, and all
other sport participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of
premises used to conduct the event or activity harmless with respect to any and all injury, disability, death, or loss
or damage to person or property, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. IF A MINOR, A PARENT OR GUARDIAN MUST SIGN.