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{name}   {dob}

{address}   {phone}

For and in consideration of the permission of the Asiatic Martial Arts-Bushinkan Dojo, The Anshindokan, and all employees or instructors  thereof (Hereinafter collectively referred to as The Dojo) to use its facilities and of the execution by others of agreements similar hereto, the undersigned hereby agrees that while upon the premises of The Dojo or while using its facilities or equipment, whether at The Dojo or at any other location for the purpose of practice or demonstration, said premises, facilities, and the undersigned hereby releases The Dojo, its agents, guest instructors, and sponsoring organizations from any and all claims for personal injury, damage, or loss of any kind or description resulting from being thereon or from such use or from the acts of any persons thereon.

 The undersigned further agrees to indemnify and hold harmless The Dojo and each of its instructors, guest instructors, teachers, officers, directors, and members from and against any and all claims made or instituted against it or them, arising out of the acts of the undersigned while upon the premises of The Dojo or while using any of its facilities or equipment, whether at The Dojo or any other location for the purpose of practice or demonstration, including injury or loss to the undersigned however caused and injury or loss caused by the undersigned to any other person.  I agree and consent to the use of my image that may be captured on video, digital photography or film during the course of my training for future promotions, products, and/or events of The Dojo, its instructors, teachers, officers, directors, and members.  I understand that The Dojo is the sole owner of such documentation and hereby release The Dojo, its instructors, teachers, officers, directors, and members from any and all financial compensation/obligation to me from money that may be earned from the use of my image on promotions, products, and/or events.

I certify by my signature that I have read and understand this document in its entirety and all of my questions regarding it have been fully answered.  Furthermore, by signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against The Dojo on the basis of any claim from which I have released them herein.

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