PEAK PERFORMANCE
SPORT TAEKWONDO CAMP
October 9-10,1010
ATHLETE INFORMATION
Name : ____________________________________________________________
Date of Birth : ______________________________________________________
Name of parent (for minors) : _________________________________________
Home Address : ____________________________________________________
____________________________________________________
Phone # (home): ___________________ Phone # (cell) : ___________________
Email Address : ____________________________________________________
____________________________________________________
TKD School EMAIL : ____________________________________________________
____________________________________________________
2010 USAT Member? Yes / No USAT Membership # : _______________
AN ATHLETE PHOTO IS REQUIRED ALONG WITH THE REGISTRATION.
_______________________________________________________________________________________
PEAK PERFORMANCE
ATHLETE DEVELOPMENT CAMP
October 9-10,2010
WAIVER & RELEASE OF LIABILITY, ASSUMPTION OF RISK, AND PARENTAL CONSENT & INDEMNITY AGREEMENT
In consideration of the enrollment of myself or my minor child, on behalf of myself or the minor child and on behalf of my and the minor child’s heirs, executors, representatives, assigns and administrators, I do hereby forever waive, release, discharge, and covenant not to sue Juan Moreno, PEAK PERFORMANCE TAEKWONDO, ADVANCED TAEKWONDO SYSTEMS INC., its successors and assigns (hereinafter “ATS”), NORTHEAST SPORTS TRAINING AND REHABILITATION, LLC and NORTHEAST SPORTS TRAINING, INC., their successors & assigns (hereinafter collectively, “NESTR”) its and their agents, coaches, representatives, volunteers, owners, officers, members, directors, instructors, sponsors and the lessor of the premises at which this event takes place, from any and all demands, costs, damages, actions, causes of action or suits of any kind or nature, whether for personal injury, property damage or otherwise, that are in any way related to my or my minor child’s participation in any ATS or NESTR activity.
I further agree, on behalf of myself and the minor child and on behalf of the minor child’s heirs, executors, representatives, assigns and administrators, to indemnify and hold harmless Juan Moreno, Peak Performance , ATS and NESTR its and their agents, coaches, representatives, volunteers, owners, officers, members, directors, instructors, sponsors and the lessor of the premises at which any Peak Performance, ATS or NESTR activity takes place, from any and all liability arising from any and all claims (including for the negligence of any of them that may result in personal injury, accident, illness or death), demands, costs, attorneys fees, damages, actions, causes of action or suits of any kind or nature that are in any way related to my or my minor child’s participation in this activity.
I fully understand the nature of Olympic-style Taekwondo sparring activities, full-contact sparring and the physical conditioning program required for such activities. Furthermore, I believe that my experience and capabilities, or those of my minor child, are sufficient to participate in the training programs provided by Juan Moreno, PEAK PERFORMANCE, ATS and NESTR. I understand that Taekwondo sparring activities along with the physical conditioning program required for such activities involve risks and dangers of serious bodily injury, including permanent disability, head injury, paralysis and death. These risks and dangers may be caused by myself or the minor child’s own actions or inactions or by others participating in the activity. I acknowledge that I have assumed these risks.
In the event I am or my minor child is injured in any PEAK PERFORMANCE, ATS or NESTR activity, I hereby authorize PEAK PERFORMANCE, ATS and NESTR to provide medical treatment or assistance by licensed medical professionals or athletic trainers. On behalf of myself or the minor child and on behalf of my and the minor child’s heirs, executors, representatives, assigns and administrators, I do hereby forever waive, release, discharge, and covenant not to sue PEAK PERFORMANCE, ATS and NESTR its and their agents, coaches, representatives, volunteers, owners, officers, members, directors, instructors, sponsors and the lessor of the premises at which medical treatment or assistance is provided, for any medical treatment or assistance provided. I further agree, on behalf of myself or the minor child and on behalf of my and the minor child’s heirs, executors, representatives, assigns and administrators, to indemnify and hold harmless PEAK PERFORMANCE, ATS and NESTR its and their agents, coaches, representatives, volunteers, owners, officers, members, directors, instructors, sponsors and the lessor of the premises at which medical treatment or assistance is provided from any and all liability arising from any and all claims (including for the negligence of any of them that may result in personal injury, accident, illness or death), demands, costs, damages, actions, causes of action or suits of any kind or nature that are in any way related to the provision of any medical treatment or assistance. I further agree to pay for any and all financial obligations incurred as a result of any such medical treatment or assistance.
I have read this Agreement, fully understand its terms and understand that I or my minor child have given up substantial rights. I further acknowledge that Juan Moreno, PEAK PERFORMANCE, ATS and NESTR have relied on my execution of this Agreement as an inducement to enroll me or my minor child in this Taekwondo Program. I represent and warrant to Juan Moreno, PEAK PERFORMANCE, ATS and NESTR that I have signed this Agreement freely and without any inducement, coercion or assurance of any nature and that I intend it to be a complete and unconditional release of all liability and indemnification to the fullest extent allowed by the law. I fully acknowledge that if any portion of this Agreement is held to be invalid, the remaining portions shall continue in full force and effect.
___________________________ ___________________________ ____________
Participant’s Printed Name Participant’s Signature* Date
__________________________ ___________________________ _____________
Parent/Guardian’s Printed Name Parent/Guardian’s Signature Date
*I certify that I am over the age of 18 if this Agreement is not also signed by my Parent or Guardian.
PEAK PERFORMANCE
ATHLETE DEVELOPMENT CAMP
October 9-10,2010
Visual Media Release
I hereby give Juan Moreno, Tom Chea, Peak Performance, Advanced Taekwondo Systems and Northeast Sport Training and Rehabilitation the absolute and irrevocable right and permission, with respect to the photographs, videotapes and/or any other visual media that have been taken of me (or which include me along with others) at this event:
1. To use, re-use, publish and re-publish the same in whole or in part, individually or in conjunction with other photographs or images, in any medium whatsoever, including but not limited to illustrations, promotions, and advertising.
2. To use my name in connection therewith if so chosen.
I hereby release and discharge Juan Moreno, Tom Chea, Peak Performance, Advanced Taekwondo Systems and Northeast Sport Training and Rehabilitation from any and all claims and demands arising out of, or in connection with the use of the photographs, video, and/or any other visual media including all claims for libel.
I am over eighteen (18) years of age. I have read the foregoing and fully understand the contents thereof.
Name of Athlete ________________________________________________
Name of parent (if minor) __________________________________________
Signature______________________________________________________
Date ___________________________________________________
AWARD CEREMONY AND RECEPTION
Sunday October 10th, 2010
6:00 – 10:00 pm
After the completion of training on Sunday September, there will be an Award Ceremony and Reception for all participating coaches, athletes and families. event will be hosted by Coach Juan Moreno. Food and refreshments will be served.
Be sure to join us for this exciting conclusion to the 2nd Annual Peak Performance Camp. Please indicate if you will attend by circling the appropriate response below. There will be a $20 charge for each person.
Will you attend the Award Ceremony & Reception? YES or NO
Name: _______________________________________________
Number of additional family members : _____________________
Check or Money Order for the reception should be made payable to
ADVANCED TAEKWONDO SYSTEMS and attached to this form. Thank you.
25 Coronado Rd
Warwick, RI 02886
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