Student Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Emergency Contact Details *

First Name

Last Name

*

Phone

(###)

###

####

*

We consent for the club to use pictures and videos of me for club media, internet and literature.

Yes - I Consent

No - I DO NOT Consent

*

I agree to abide by the rules of Waverley Judo Club. I also declare that I will be respectful of others at all times and will participate in the true spirit of Judo.

Liability Waiver: *

I recognise the inherent risks of participating in Judo. If the participant is under the age of 18, as the parent/guardian of the above-mentioned child, I recognise the inherent risks of participating in Judo. I agree on behalf of myself or my child, to release and hold harmless Waverley Judo, its officers, and employees from all liabilities and claims that arise from mine or my child’s participation.

Accepted

Assumption of Risk *

I understand the risks involved and consent to participate in the activities. If the participant is under the age of 18, I understand the risks involved and consent for my child to participate in the activities. I assume all responsibility for any risks, injuries, or damages, know or unknown, which might occur as a result of mine or my child’s participation.

Accepted

Date Joined

MM

DD

YYYY