Frank’s Enterprise Karate Studio

Integrity (Home of Discipline) Respect

948 W. 59th Place

Los Angeles, CA 90044

(323) 447-7468

Participant’s Waiver

Student’s Name:___________________________Age_____Date of Birth_________Tel#__________

Address________________________________________ City___________________State_____Zip_______

Allergies to drugs or foods___________________Any special medications_______________

Physician/HMO name:_________________________________Phone____________________________

Father/Guardian name: ___________________________________________________________________

Mother/Guardian name: __________________________________________________________________

Emergency Contact Person: ______________________________________________________________

Monthly fee is $75.00 due on the 1st Monday of each month.

Authorization To Treat a Minor

I, the legal guardian, of the child listed above, do hereby authorize and consent to any X-ray examination, anesthetic, medical, or surgical treatment rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the medical Practice Act or a dentist under the Dental Practice Act and their staff in the facilities in the state of California Department of Public Health. Further, I understand that my child will be participating in dangerous activities and agree to pay for my child’s medical expenses

Release of Liability

Because of the Covid-19 Pandemic, each student is responsible to practice safe distancing and to use a face mask while on the premises, In consideration of the acceptance of the application name above, as a participant in any programs and/or activities of FEKS and its member chapter, my child and I hereby agree to assume all risks attendant upon my child, while participating in martial arts training with FEKS activities and myself. I and my child hereby waive, release, and discharge any and all claims for damages for death, personal injury, or property damage which I or my child may have, or which may hereafter accrue to me or my child, as a result of my child participation in martial arts with FEKS or activities. I agree to indemnify and hold harmless from liability FEKS, it’s members chapters and/or any of the agents, servants, or employees by reason of any accident, death, injury, or damages to persons or property which I or my child may suffer while participating in martial arts (FEKS) activities. This release is intended to discharge in advance FEKS, it’s member chapters, and/ or any of their agents, servants, or employees by reason of any accident, death, injury or damages to persons or property which I or my child may suffer, from and against any and all liability arising out of or connected in any way with me or my child’s participation in the martial arts program (FEKS) program and/or activity, even though that liability may arise out of negligence or carelessness on the part of the persons or entities mentioned above.

It is further understood and agrees that this waiver, release and assumption of risk are to be binding on y heirs and assigns, and the heirs and assigns of my child. I agree to assume all responsibilities for and property damage or injury to any person caused by me or my child while participating in the martial arts program (FEKS).

I have read, understand and approve the AUTHORIZAYION TO TREAT A MINOR and release any and all liabilities to FEKS located at 948 W. 59th Place, Los Angeles, CA 90044.

Print name of participant – Child	Date

Signature of parent or Legal Guardian	Date