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  Moon Lee Tae Kwon Do Association

  Participation form and Public Liability

  Participation Form

  Medical History

  RELEASE AND INDEMNITY

  Photo/Video Release

  The information requested is needed to assist the service in providing training and instruction for you/your children The answers you provide will be treated as strictly confidential and will not be used for way other purpose. Please complete one for per student. Please complete all pages.IF STUDENT IS UNDER 18 YEARS OF AGE. A PARENT/GUARDIAN MUST ENTER DETAILS ON ALL THESE FORMS

  First Name*

  Last Name*

  Email*

  Date Of Birth

  Address*

  City*

  Postal Code

  Occupation

  Home Phone

  Mobile Phone

  Work Phone

  PLEASE PROVIDE ANY DETAILS about you / your child which may assist your Instructor to understand any underlying issues and provide better training and instruction for you/your child? eg.Self confidence issues. Discipline.PLEASENOTE: no medical details here please, next page.

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  Moon Lee Tae Kwon Do Association

  Text*

  Does the student suffer from any of the following?

  Athsma

  No   Yes

  Epilepsy

  No   Yes

  Diabetes

  No   Yes

  Heart Disease

  No   Yes

  Does the student suffer from any other Medical Condition?*

  No   Yes

  eg. Disability, Disorders, Behavioural Disorders, Previous Injuries

  If yes, list condition and details

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  <p>NOTE: MOON LEE TAE KWON DO Instructors are not medical officers, they have no training in medical conditions, therefore are unable to supervise or administer medications.Students who require medication should be able ot administer their own or if student under 18 years of age parent/guardian should be present at classes, competitions, camps or functions to administer medications.<br></p><p><br></p><p>Doesthe student experience any ALLERGIC REACTIONS or Intolerances? eg. Be Sting,Penicillin,Lactose Intolerant<br></p><p>YESNO<br></p><p>Ifyes, list details<br></p><p>________________________</p><p><br></p>

  Does the student experience any ALLERGIC REACTIONS or Intolerances? eg. Be Sting,Penicillin,Lactose Intolerant

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  ALLERGIC REACTIONS

  No   Yes

  If yes, list details

  MEDICAL CONSENT I hereby give my permission for the Moon Lee Tae Kwon Do Association Instructors or its Assistants to seek medical attention for the above student in the event of an accident/emergency.

  Medical Consent

  No   Yes

  _________________________ Signature OR Parent/Guardian if Student is under 18 Date ________________________ Parent/ Guardian Name (please print)

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  <h2 style="text-align: center;">RISK WARNING ACKNOWLEDGMENT AND ASSUMPTION OF RISK</h2><h4 style="font-size: 14px; text-align: center;">RELEASE AND INDEMNITY</h4><p>WARNING:- THIS IS AN IMPORTANT DOCUMENT WHICH AFFECTS YOUR LEGAL RIGHTS AND OBLIGATIONS. READ IT CAREFULLY AND DO NOT SIGN IT UNLESS YOU ARE SATISFIED THAT YOU UNDERSTAND IT. IF YOU HAVE ANY QUESTIONS PLEASE ASK OUR REPRESENTATIVE. RECREATIONAL ACTIVITY PROVIDER: MOON LEE TAE KWON DO<br>PARTICIPANT'S NAME: M A D I S O N N G U T E N<br>PARTICIPANT'S DATE OF BIRTH:<br>29/052014<br>a participant under 1 8yearsparentguardianto enterdetails and sion forms)</p>

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  <p>WARNING AND ACKNOWLEDGEMENT OF RISKS. INJURY AND OBLIGATIONS </p><p><br></p><p>I acknowledge and understand that:<br>- The RecreationalActivity (activity) I am to undertakemay involve a significant degrec of risk of physical harm or injuryand that by participating. I am exposed ot this potentialrisk.<br>- ThatI amnotrequiredot engage ni hte activity and do os of my own volition.<br>- Imay be injuredparticipating inthe activity.<br>- My personalpropertymaybe lostor damaged while participating inthe activity.<br>-Other personsparticipatingni thisactivitymaycausemeinjuryormaydamagemyproperty<br>- I maysuffer injuryor damage tom y personal property as aresult of neolicenceor breach ofcontract oft h e Recreational Activity Provider.</p><p>- I assume the sole risk o fand responsibility for any injury or property damage resulting from my participation in the activity.</p><p><br></p>

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  <p>RELEASE AND INDEMNITY TO THE RECREATIONAL ACTIVITY PROVIDER<br><br></p><p>Inconsideration of my payment for participating ni ht<br>e activity(andexcepttotheextentthatthesamemaybe precludedby statut) IAGREE TO RELEÄSEAND INDEMNIFY theRecreational ActivityProviderasfollows:<br>I participate in the activityat m y own risk a n dresponsibility<br>I release. indemnify and hold harmless the Recreational Activity Provider, i t s servants and agents. from andagainst a l la n danyactions or claimsw h i c hm a yb emade by me oro nm y behalf or byother partes for or in respectof o rarising outofany injury, loss or damagecaused to m eormyproperty whether by negligence, breach ofcontract orinanywaywhatsoeverorany liabilitythatresultsfromthe breach of anexpressor implied warranty that the recreational services or activity wil be renderedwith<br><br></p><p>I n t h e e v e n t t h a t I am i n j u r e d o r my p r o p e r t y i s d a m a g e d . I w i l l b r i n g no c l a i m , l e g a l or o t h e r w i s e againstthe Recreational ActivityProviderinrespecto fthatiniuryor damasc</p><p><br></p>

  Single Line

  Single Line

  Phone

  MEDICAL HISTORY

   

  RELEASE AND INDEMNITY TO THE RECREATIONAL ACTIVITY PROVIDER

  PHOTO / VIDEO/DIGITALIMAGE-RELEASEFORM ALLPARTICIPANTS TO SIGN ... or parents of under 18 participants I hereby give permission for _____________ Students Name image to be photographed or video taped in a professional manner by, and used by the Mon Le Tae Kwon Do Association for the following, Inclusion in Associations website www.moonlee.com.au Names of students will not be published.Inclusion in a specific class venue website. eg.YMCA website, if class held there. Names of students will not bepublished.Inclusionin Associations promotional material. eg. Advertising flyers. Names of students will not be published.Inclusion inAssociations promotional material eg. Class noticeboards, Club or Class photos, Club/Class newsletters. Names of students may be published. Events videos for students memorabilia (gradings/competitions/demonstrations etc) Only available for purchase to members of The Association. Names of students may be announced on films. Inclusion in Newspapers or Magazines. Names of students may be published. I hereby agree to my/my child's participation without financial compensation, and I understand that this releases The Association from any future claims. as well as from any liability arising from the use of above said material. All such Material will be the property of the association. Student Signature or Parent/Guardian Signature if student under 18 sears of age If applicable, Parent/Guardian Name ____________ ____________ Signature____________(Please insert name of participant if under 18 years of age) Date ____________ Witness____________ Date___________

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