RELEASE/DISCLOSURE AGREEMENT  

ENROLLING IN VICTORY KARATE/VKfit WITH ERIK AKUTAGAWA:

• I will uphold the high standard of excellence of Victory Karate/VKfit by always:

  1. Respecting myself and others;

  2. Striving to be the very best I can be;

  3. Presenting & conducting myself in a professional manner;

  4. Being an encouragement to others; and

  5. Promoting the virtues of Victory Karate/VKfit.

• I commit to participate in this karate/fitness program offered by Erik Akutagawa, and do so voluntarily on my own volition.

• I understand that this is a karate/fitness program, that there will be physical contact (for karate), and that there is a possibility for injury.

• I assume full responsibility for any injuries I incur through this program, and do not hold Mr. Akutagawa or the training location responsible in any manner.

• I agree not to file any claims or sue Mr. Akutagawa or the training location for any injury-related or other claim I may have arising out of such participation.

• I grant all rights to Erik Akutagawa to use, re-use, publish, and republish any comments, statements, or photographic images, whether written or verbal, intact or in part, composite or distorted, without restriction for any advertising, promotion, or any other purpose.

• I declare that I am 18 years of age or older, or have full parental consent to all of the above if I am 16 years of age or older.

Signed: _______________________________ Date:_____________

Name (printed): _______________________________


Parent/Guardian signature if under 18: ________________________

Parent/Guardian name (printed): _____________________________















Personal Information:

Name: _____________________________________________________

Address: ___________________________________________________

City: __________________________________   Zip: ________________

Phone: _____________________________

Secondary phone: _____________________________

Email address: _______________________________

Birthdate: __________________



Emergency contact information:

Name: _____________________________________________________

Phone: _____________________________

Secondary phone: _____________________________



Other information:

Occupation: _________________________________________________

Prior training: ________________________________________________

Other interests: _______________________________________________


How did you find out about Victory Karate/VKfit?

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Why are you interested in training with Victory Karate/VKfit? What do you want to accomplish through your training with Victory Karate/VKfit?

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