3600 Kalamazoo Ave
Grand Rapids, Michigan 49508
3600 Kalamazoo Ave
Grand Rapids, Michigan 49508

Shinsei-Hapkido/ Shinsei Jujitsu Waiver and release of liability and agreement to participate Form

In consideration of being permitted to participate in any way, including travel to and from, in a martial arts tournament, class, practice, clinic, and related events and activities of the Beverly Karate School and Shinsei Hapkido/Shinsei Jujitsu and Karate for Christ of Michigan,


I Hereby:

1.         Acknowledge that I am familiar with the sport and Martial Art of Shinsei-Hapkido and understand the rules governing the class and tournaments, and the importance of following these rules.

2.         Agree that I will immediately advise my supervisor of any conditions in equipment I find unsafe prior to participating.

3.         Acknowledge and fully understand that I will be engaging in a contact sport that might result in serious injury, including permanent disability or death, and severe social and economic losses due to not only my own actions, inactions, or negligence, but also to the actions, inaction or negligence of others, the rules of the sport and Shinsei Hapkido/Jujitsu, or conditions of the premises or of any equipment used. Further, I acknowledge that there may be other risks not known to me or not reasonably foreseeable at this time.

4.         Knowing the risks involved in the sport and Martial Art of Shinsei Hapkido/Jujitsu, I assume risk and accept personal responsibility for the damages following such injury, permanent liability, or death..

5.         I release, waiver, and discharge and covenant not to sue Shinsei Hapkido/Jujitsu, Beverly Reformed Church, Dan Averill, Margaret Timmer, affiliate clubs, administrators, directors, agents, coaches, and other employees of the organization, event officials, medical personnel, other participants, their parents, guardian(s), supervisors, coaches, sponsoring agencies, sponsors, advertisers, and if applicable, owners, leasers, and leasees of the premises used to conduct the event, all of whom are hereinafter referred to as “releasee,” from any and all claims, demands, losses, or damages on account of injury, including permanent injury and death, or damage to property, caused or alleged to be caused in whole or in part by the negligence of the releasee or otherwise.

6.         Parents(s) or legal guardian(s) or minor participants (age 18 or below) additionally agree that they instruct the minor participant to the above warnings and conditions and their ramifications, and that they consent to the minor’s participation.

7.         Agree that the instructor, for disciplinary action, may use physical exercise to discipline the participant, and also may remove participant from class for disciplinary action.

8.         Allow this form to serve as a medical release to allow such actions and institutions as mentioned taking me for such medical treatment as needed.

9.         Agree to pay $10.00 per week for Shinsei Hapkido/Jujitsu lessons, due each week that you attend. (Prices subject to change as necessary)

10.        Agree to find a Bible believing church and to attend said church and to be activity involved.


I have read the above waiver and release, understand that I give up substantial rights by signing it, and knowing this, sign it voluntarily. I agree tentirely of my own free will.


Participant: __________________________________ Signature: ___________________________________



Phone:______________________________ Email: ______________________________________________

Insurance provider and policy #: _____________________________________________________________

Church attending: _________________________________________________________________________

Parent/Guardian: ______________________________Signature: ___________________________________



Member of the World Kido Association, Shinsei Hapkido and the International Sung Ja Do Association







Phone: 616 455-4445

Web site: www.kfcom.org
























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