2 Week Free Pass Form

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Emergency Contact Name *

First Name

Last Name

Assumption of Risk and Release Liability *

I, the undersigned, do hereby voluntarily submit my application for attendance and participation in Cambridge Kyokushin Karate Classes and do hereby assume full responsibility for any and all damages, bodily injuries, death or losses of any kind and description that I may sustain or incur, if any, while attending or participating, and I hereby waive all claims and forever release and/or hold harmless Cambridge Kyokushin Karate and the New Zealand Karate Organisation Kyokushin Kaikan incorporated, the promoters, participants, officials and sponsors of said Martial Arts Organisations individually or otherwise, for any claim for injuries that I may sustain as a result of the said classes

I Agree to Assumption of Risk as outlined above

and that I am over 18 years of age or

I am the parent/caregiver of the student