Melbourne Budo AcademyAncient Theory, Modern PracticeOffering world class instruction in the traditional martial arts of Aikido, Brazilian Jiu Jitsu and Judo. Release Form TERMS & CONDITIONS OF PARTICIPATION * I agree, in consideration of being allowed to access and participate in Martial Arts Training Program with Melbourne Budo Academy (the Program) to accept the following terms and conditions: (Risks and Compliance with Directions): 1. I understand and agree that participation in the Program involves, without limitation, martial art activities of the following nature: full contact sparring, wrestling / grappling, throws, contact strikes, submission techniques, (the Activities) and that participation in the Activities will expose me to inherent risks that can result in physical injury detrimental to my health. 2. I understand and agree that the Activities are physically and mentally challenging and will expose me to risks which cannot be eliminated completely, including but not limited to, sprains, damage to ligaments and tendons, concussions, dislocations, and broken limbs. These risks may arise not only from my own actions when undertaking the Activities, but also from the actions of others participating with me as part of the Activities. 3. I understand and agree that I fully understand the risks involved in the Activities and confirm that I am willingly and voluntarily participating in the Activities entirely at my own risk. 4. I understand and agree that when participating in the Activities to conduct myself in a safe and mature manner and in accordance with the instructions from my instructors. 5. I acknowledge and agree that if I feel that any part of the Activities is unsafe or if I do not want to participate in the Activities for any reason, I will immediately notify my instructors and stop my participation in the Activities until a mutually agreed course of action is reached. 6. I confirm I am physically capable of participating in the Activities and that I have no existing medical condition which precludes or should reasonably preclude my participation in the Activities. (Release and Indemnity): 7. I acknowledge and agree to release and forever discharge Melbourne Budo Academy (the Released Parties) from all proceedings, claims, demands, losses and detriment of any nature, whether in tort or in contract, which I have or may have at any time against the Released Parties as a result of my participation in the Activities. 8. I acknowledge and agree to indemnify the Released Parties and keep the Released Parties indemnified against all proceedings, claims, demands, losses and detriment of any nature that may be brought or made against the Released Parties as a result of my participation in the Activities, including in respect of any failure on the part of the Released Parties to exercise due care and skill in respect of the Activities. This indemnity includes an indemnity in respect of costs, damages, and expenses that may be incurred by the Release Parties in defending any such proceedings, claims and demands. 9. I acknowledge and agree that this waiver and release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law within Australian states and territories. WARNING UNDER THE AUSTRALIAN CONSUMER LAW AND FAIR TRADING ACT 2012 Under the Australian Consumer Law (Victoria), several statutory guarantees apply to the supply of certain goods and services. These guarantees mean that the supplier named on this form (Melbourne Budo Academy) is required to ensure that the recreational services it supplies to you (i.e. the Activities): - are rendered with due care and skill; and - are reasonably fit for any purpose which you, either expressly or by implication, make known to the supplier; - and might reasonably be expected to achieve any result you have made known to the supplier. Under section 22 of the Australian Consumer Law and Fair Trading Act 2012, the supplier is entitled to ask you to agree that these statutory guarantees do not apply to you. If you tick that you certify, you will be agreeing that your rights to sue the supplier under the Australian Consumer Law and Fair Trading Act 2012 if you are killed or injured because the services provided were not in accordance with these guarantees, are excluded, restricted or modified in the way set out in this form. NOTE: The change to your rights, as set out in this form, does not apply if your death or injury is due to gross negligence on the supplier's part. Gross negligence, in relation to an act or omission, means doing the act or omitting to do an act with reckless disregard, with or without consciousness, for the consequences of the act or omission. See regulation 5 of the Australian Consumer Law and Fair Trading Regulations 2012 and section 22(3)(b) of the Australian Consumer Law and Fair Trading Act 2012. I certify that I have read this document and that I fully understand its content. I am aware that this is a release of liability and binding legal document and I sign it of my own free will. Name * First Name Last Name Contact Number * Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country PHYSICAL READINESS QUESTIONNAIRE * The required training and exercises within our Martial Arts Training Programs with Melbourne Budo Academy consists of, but not limited to the following: Sparring, Contact Wrestling, Throws, Contact Strikes, Submission Techniques, etc. (the Activities) and participants are required to complete the questionnaire below as a prerequisite before commencing the Activities, and for assessment of any special needs and/or considerations. Please check the boxes if any of these apply to you. Leave blank if not. Has your doctor ever said you have a heart condition or vascular disease? Do you ever experience chest pains? Have you experienced any chest pain recently? Do you ever feel faint, dizzy, lose balance or lose consciousness? Has your doctor ever said you have high blood pressure (140/90)? Are you taking any medication for blood pressure or a heart condition? Are you a male over 35 or, a female over 45 and not accustomed to exercise? Do you have a bone or joint problem that could be made worse by a change in your physical activity? Do you suffer from asthma? Do you suffer from any other respiratory problems? Do you suffer from diabetes? Do you suffer from epilepsy? None of the above Do you currently suffer from any illness not mentioned here and do you know of any other reason why you should not participate in physical activity? Do you suffer from any allergies? NOTE: If you have answered YES to any of the above questions, you may be required to provide a doctors certificate/clearance before you will be allowed to participate. Emergency Contact Name * First Name Last Name Emergency Contact Number * I, as the participant, agree * To the best of my knowledge I have answered the questions above truthfully. I understand and agree that it is my responsibility to inform Melbourne Budo Academy of any conditions or changes in my health, now and ongoing, which might affect my ability to participate safely in required activities. Electronic Signature * First Name Last Name Date * Thank you!
