Judo Workshop Registration Form

1st Martial Arts Club Judo Workshop
Saturday, October 12, 2002
Cal State LA, Physical Education Building Room 213
Hosted by: Martial Arts Club Email: mac@calstatela.edu Website: www.calstatela.edu/orgs/mac

Official Registration Form

Pre - Registration Fee $25  (includes T-shirt, please specify size below)
At-the-Door Registration Fee $30 (T-shirts limited to sizes and quantity at the door)
Entry Forms may be printed from the website at www.calstatela.edu/orgs/mac

Deadline for Applications (pre-registration): 10/11/2002 (must be received by the stated date)
Make registration fees payable to: MAC - Martial Arts Club
Submit form and fees to:

Money Orders/Cashiers Checks only!
Asian Pacific American Student Resource Center (c/o MAC)
5154 State University Drive, 2nd floor
Los Angeles, CA 90032

Important:    Please fill out completely & print in capital letters only!

Last Name                                                                               First Name                                                               

Home Address                                                                       City                               State            Zip                 

Home Tel #: (            )                                     Email:                                                                                               

School:                                                                                   Instructor Name:                                                  

School Address                                                                   City                               State            Zip                 

Applications will not be processed and returned if the information in this box is not completed.

Sex: __________  
Age ________ 
Date of Birth _______-________-________   Belt Rank ____________________

Pre-registration $25                   At-the-door $30

Total enclosed: $__________ (make checks payable to Martial Arts Club) NO REFUNDS

Liability Release and Indemnity
In consideration of the acceptance of my participation in the 1st Martial Arts Club Judo Workshop, hosted by the Martial Arts Club (MAC), I agree to assume the risk incidental to such participation (which risk may include, among other things, muscle injuries and broken bones or death) and, on my own behalf, and on behalf of my heirs, executors and administrators, release and forever discharge the released parties defined below, of and from all liabilities, claims, actions, damages, costs or expenses of any nature arising out of or in any way connected with my participation in such activity, and further agree to indemnity and hold each of the released parties harmless against any and all such liabilities, claims, actions, damages, costs or expenses, including but not limited to , attorney’s fees and disbursements.  The released parties are the Martial Arts Club (MAC), California State University Los Angeles, the workshop production team and the officers directors, employees, agents, representatives, successors and assigns of each of the foregoing entities.  I understand that this release and indemnity agreement includes any claims based on the negligence, action or inaction of any of the above released parties and covers bodily injury (including death) and property damage, whether suffered by me, before, during or after such participation.  I declare that I am physically fit and have the skill level required to participate in this particular event.  I further authorize medical treatment for myself, at my cost, if the need arises.
I further grant the release parties the right to photograph and/or videotape me and further to use my name, face, likeness, voice and appearance in connection with exhibitions, publicity, advertising and promotional materials without reservation or limitation.  The released parties are, however, under no exercise said rights herein granted.
I have read this agreement, fully understand itÂ’s terms, understand that I (and the minor, if applicable) have given up substantial rights by signing it and have freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by the law and agree that if any portion of this agreement is held to be invalid that the balance, notwithstanding, shall continue in full force and effect.

Date:                       Participate Signature:                                                          

Date:                       Parent/Legal Guardian Signature:                                                  Full Name                                           
(Parent/Legal Guardian Signature is mandatory for competitor age 17 & younger.  Unsigned application will be returned unprocessed)