I, ___________________________________________the undersigned, wish to register myself as a participant of the North Central Region General and Regional Tournaments 2009.

I recognize that participation in such an event, even when well supervised and well managed, may pose a risk to myself and I agree to assume such a risk. I understand the basic nature of Karate and that the performance of this activity involves significant risks, including the potential for permanent paralysis and death. I knowingly and freely assume all suck risks, both known and unknown, even if arising from the negligence of the Releasees or others, and I accept full responsibility for my participation in this event.

In case of injury, I authorize the staff of the clinic to render first aid and/or obtain whatever medical treatment he/she deems necessary for my welfare. I further understand and agree that I will be financially responsible for all charges and fees incurred in the rendering of said treatment, regardless of whether my medical insurance would cover such charges and fees.

I, the undersigned, herby release, indemnify and hold harmless the Regents of the North Central Region General and Regional Tournament, Midwest Karate Association, and Southwest High School, their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors or premises used to conduct the event with respect to any and all injury, disability, death, medical, and/or accident expenses, any loss or damage to property, which I may incur during my involvement in the (Date:)__________  general and regional Karate Tournament.                                                                      

I understand the North Central Region, employees, and representatives of Midwest Karate Association reserve the right to dismiss the undersigned participant due to inappropriate behavior that could lead to physical or emotional harm to him/her or others. I also understand that the General and Regional Tournaments reserves the right to remove participants whose behavior contributes to the continued disruption of the clinic.

I have read, understand, and agree to the terms and conditions of this liability waiver which relates to my participation in the (Date:)_____________ general and regional Karate Tournaments.

Participant Signature: _____________________________________________________
Participant Phone Number: ____________________________ Date : ________________

Medications/medical conditions of which the clinic staff and emergency service personnel need to be made aware:

I understand, agree, and acknowledge that some activities may be of a hazardous nature and/or include physical and/or strenuous activity. Understanding this, I state to the best of my knowledge, I have no medical condition or impairment, including the use of medication that might inhibit my active participation in this Karate Tournament.

I understand I am required to have accidental medical coverage for myself, and I verify that the information provided on my insurance policy is accurate and true.

Please name your insurance provider and any information pertaining to medical insurance for yourself.

Insurance Provider : ___________________________________________________
Policy Number : _______________________________________________________

I verify that the information provided on my insurance is accurate and true.

Print Name : __________________________________________________________
Participant Signature : ___________________________________________________