Name
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First Name
Last Name
Parent/Guardian or Spouse's Name
Email
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How did you hear about Buzz Durkin's Karate School?
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Phone
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Date of Birth
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MM
DD
YYYY
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Are you currently training, or have you ever training in Martial Arts before?
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If "yes," where and for how long?
Liability waiver
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I recognize and acknowledge that there is a known risk of injury involved in the participation of Okinawan karate. I agree to assume this risk and agree that Buzz Durkin’s Uechi Karate School, INC will not be held liable for any damages not caused by or resulting from the negligence of the owners, operators, or persons in charge of such establishment, or their agents, servants, or employees. I understand also that I do not have to participate in any activity or training exercise which I feel is not in my best interest. I consent to any photos and videos of my person or my child to be used for any future projects and marketing material including social media.
COVID waiver of liability
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I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that Buzz Durkin’s Uechi Karate School, INC has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that Buzz Durkin’s Uechi Karate School, INC cannot guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Buzz Durkin’s Uechi Karate School, INC staff and other Buzz Durkin’s Uechi Karate School, INC clients and their families. I voluntarily seek services provided by Buzz Durkin’s Uechi Karate School, INC and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment. I attest that:* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.* I have not traveled internationally within the last 14 days.* I have not traveled to a highly impacted area within the United States of America in the last 14 days.* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by state or local public health authorities. * I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19. I hereby release and agree to hold Buzz Durkin’s Uechi Karate School, INC harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of Buzz Durkin’s Uechi Karate School, INC, or that may otherwise arise in any way in connection with any services received from Buzz Durkin’s Uechi Karate School, INC. I understand that this release Buzz Durkin’s Uechi Karate School, INC from any liability or claim that I, my heirs, or any personal representatives may have against Buzz Durkin’s Uechi Karate School, INC with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Buzz Durkin’s Uechi Karate School, INC. This liability waiver and release extends to Buzz Durkin’s Uechi Karate School, INC together with all owners, partners, and employees.
