Event Authorization Form

Read and Initial the Terms and Conditions Below

(Check to Initial) I [(we) the undersigned parent (s) or guardian (s) of] a minor/ an adult, do hereby authorize and consent to any x-ray exam, anesthetic, medical or surgical diagnosis rendered under the general or spe-cial supervision of any member of the medical staff, emergency room staff, or dental staff licensed under the provisions of the Medicine Practice Act or Dental Practice Act and on staff of any acute general hospital holding a current license to operate a hospital from the De-partment of Public Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power to render care which the aforementioned physician in the exercise of his best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. The student and/or parent assumes all risks inherent and incidental to the martial arts as a condition for applying for admission to this Karate Event. United Studios of Self Defense is not responsible for any injury suffered on the premises.

(Check to Initial) United Studios of Self Defense (USSD) agrees to provide martial arts lessons on a scheduled basis, as established by the studio. Group Lessons are approximately 45 minutes in length. Private lessons may consist of 1-4 students and are approximately 30 minutes in length. A 24-hour cancellation is required on private lessons if a make-up lesson is to be scheduled, or credit is to be applied to the current program. Failure to attend or complete lessons does not relieve the student from their financial obligations or payments to USSD.

(Check to Initial) All rates and discounts are based on a $280 Standardized Rate-per-Month, including the Regular Program of One Private per week, and Unlimited group classes per month. Any contracts terminated early are subject to the Standardized Rate.

(Check to Initial) The names of students and any photographs taken during studio activities may be used for promotional purposes.

(Check to Initial) Protective Gear is Mandatory. All safety equipment, apparel, and martial arts supplies must be purchased through the studio or shopbushido.com to ensure it meets the requirements of the studio.

(Check to Initial) There are No Refunds for Tuition or ProShop fees. Studio Credit only.

Responsible Party