DAILY HEALTH SCREENING
 
This form MUST be filled out and turned in each day a student is training in person. You may turn this form in either electronically (preferred) or at the location by adult student or legal guardian. Forms may not be submitted a day(s) in advance, as we need to assess health daily. 
 
If filling this out electronically, please submit prior to 12:00 pm so we can print the list and have it with us at the training location.


 
Symptom Check List

People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness.

If you answer "yes” to any of these symptoms, do NOT come to class today. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:

  • Fever or chills
  • Temperature above 99.6-degrees
  • Cough
  • Shortness of breath or difficulty breathing
  • Fatigue
  • Muscle or body aches
  • Headache
  • New loss of taste or smell
  • Sore throat
  • Congestion or runny nose
  • Nausea or vomiting
  • Diarrhea

This list does not include all possible symptoms. The CDC will continue to update this list as we learn more about COVID-19. 

By signing this form, you verify that you or your child has not shown any of the above symptoms.


Additionally, I understand by signing this form that I will not hold Original Okinawan Karate of Holt, or any of its employees or volunteers liable or responsible for any viral, germ, bacteria or infectious disease I may contract, including covid-19.

 


August 4, 2020
INFO:   Please note that this form contains limited capacity items which are sold out. They are displayed grayed out and/or are not selectable.



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Registrant Fee: $0.00


Billing information


Billing and Payment
Billing and payment processing for Businesses' events is performed by Member Solutions, Inc. ("MSI"), and this contract is specifically assigned to MSI for all such purposes. Customer knowingly and irrevocably authorizes MSI to charge electronically Customer's bank account and/or credit card for any and all amounts due for Customer's, and anyone registering under Customer's, attendance and participation in the Event. Please note, you may see all or any portion of the following on your bank or credit card statement: "MSI*HOLTDOJO 8882448044 ONLINE REG FEE". Any returned payment will be assessed a $25.00 fee. Any unsuccessful electronic transaction is subject to a $10.00 processing fee. MSI is not responsible for any bank fees incurred by Customer. MSI has the sole right to resubmit returned or declined items (plus applicable fees) without prior notice. BILLING INQUIRIES -- 888-244-8044 or by mail to PO Box 297, Hatboro, PA 19040.

Applicant Agreement
I represent that I am the person who appears on the application above. I acknowledge and agree to the statements, terms and conditions above, as well as any applicable terms and conditions for this registration, and that by typing my name below and completing this registration form, I am electronically signing the document, which will have the same legal effect as the execution of the document by a written signature and shall be valid evidence of my intent and agreement to be bound.

Applicant Signature
Please enter your full name in the space below.
 


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By submitting this, I acknowledge that myself or child(ren) training have not shown any symptoms listed below:

-Fever or chills
-Temperature above 99.6-degrees
-Cough
-Shortness of breath or difficulty breathing
-Fatigue
-Muscle or body aches
-Headache
-New loss of taste or smell
-Sore throat
-Congestion or runny nose
-Nausea or vomiting
-Diarrhea
_____________________________________________________

In consideration of being permitted to participate in any way in the Martial Arts Program indicated below and / or being permitted to enter for any purpose any restricted area (here in defined as any area where in admittance to the general public is prohibited), the participant or parent(s) and / or legal Guardians of the minor participant named below agree:

1. I understand by signing this I will not hold Original Okinawan Karate of Holt, or any of it's employees or volunteers liable or responsible for any viral, germ, bacteria or infectious disease I may contract, including covid-19.
2. Prior to participating in the below martial arts activity or event, the student (adult or youth) should inspect the facilities and equipment to be used, and if he or she believes anything is unsafe, the participant should immediately advise the officials of such condition and refuse to participate. I understand and agree that, if at any time, I feel anything to be UNSAFE; I will immediately take all precautions to avoid the unsafe area and REFUSE TO PARTICIPATE further. If the student is a minor, the parent(s) and / or legal Guardians will instruct & assist the minor participant of the above listed procedure.
3. I / We fully understand and acknowledge that:
a. There are risks and dangers associated with participation in martial arts events and activities which could result in bodily injury partially and / or total disability, paralysis and death.
b. The social and economic losses and / or damages, which could result from these risks and dangers described above, could be severe.
c. These risks and dangers may be caused by the action, inaction or negligence of the participant or the action, inaction or negligence of others, including, but not limited to, the Releasees named below.
d. There may be other risks not known to us or are not reasonably foreseeable at this time.
4. I / We accept and assume such risks and responsibility for the losses and / or damages following such injury, disability, paralysis or death, however caused and whether caused in whole or in part by the negligence of the Releasees named below.
5. I / We HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the martial arts facility used by the participant, including it’s owners, managers, promoters, lessees of premises used to conduct the martial arts event or program, premises and event inspectors, underwriters, consultants and others who give recommendations, directions or instructions to engage in risk evaluation or loss control activities regarding the martial arts facility or events held at such facility and each of them, their directors, officers, agents, employees, all for the purpose herein referred to as “Releasee”, from all liability to the undersigned, my / our personal representatives, assigns, executors, heirs and next of kin for any and all claims, demands, losses or damages and any claims or demands therefore on account of any injury of any nature, including but not limited to the death of the participant or damage to property, arising out of or relating to the event(s) caused or alleged to be caused in whole or in part by the negligence of the releases, or any other person on the premises.
6. I / We HEREBY acknowledge that THE ACTIVITIES OF THE EVENT(S) ARE VERY DANGEROUS and involve the risk of serious injury and / or death and / or property damage. Each of THE UNDERSIGNED also expressly acknowledges that INJURIES RECEIVED MAY BE COMPOUNDED OR INCREASED BY NEGLIGENT RESCUE OPERATIONS OR PROCEDURES OF THE RELEASEES.
7. Each of the undersigned further expressly agrees that the foregoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as is permitted by the law of the Province or State in which the event is conducted and that if any portion is held invalid, it is agreed that the balance shall, not withstanding continue in full legal force and effect.
7. On behalf of the participant and individually, the undersigned parent(s) and / or legal guardians for the minor participant executes the Waiver and Release. If, despite the release, the participant makes a claim against any of the Releasees, the parent(s) and or legal guardian(s) will reimburse the Releasee for any money which they have paid to the participant, or on his behalf, and hold them harmless.

I have read this Release and Waiver of Liability, Assumption of Risk and Indemnity Agreement, fully understand it’s terms, understand that I have given up substantial rights by acknowledged it, and have done so freely and voluntarily without any inducement, assurance, or guarantee being made to me and intend my acknowledgement on this form to be complete and unconditional release of all liability to the greatest extent allowed by law.

Media Recording Release

I do hereby grant unrestricted permission to Original Okinawan Karate of Holt to use the image of myself or my child in print, video, social, and digital media. I agree that these images may be used by Original Okinawan Karate of Holt for a variety of purposes, and that these images may be used without further notifying me. I do understand that the last name will not be used in conjunction with any video or digital images. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the Original Okinawan Karate of Holt Web site.

Check this box to indicate that you have read and agree to all of the above terms & conditions