January 20th 2018
Choose registration below
- Print copy of “Registration Form“
- Kelly Recreational Center Waiver – Lakeland Florida will be provided at the event. Unaccompanied minors will not be able to attend without this form completed by parent or legal guardian. If you are under 18, print Kelly Rec. form and have parent/guardian sign and mail with payment.
- Include payment
- Mail to: John Wilkerson 2913 Banyan Hill Ln, Land O Lakes FL. 34639
- Complete form below
- Once you complete the form, an invoice will be sent to your email address for payment via SquareUp.com
- Allow up to 24 hours for invoice to appear in your email box. Check SPAM box.
- Complete payment via emailed invoice
- Kelly Recreational Center Waiver – Lakeland Florida The waiver for Kelly Rec. will be provided at the event. Unaccompanied minors will not be able to attend without this form completed by parent or legal guardian. If you are under 18, print Kelly Rec. form and have parent/guardian sign and bring form to event.
Online registration for this event constitutes acceptance of the following Image Use Release and Liability Waiver *see below
Release – Image Use:
I do permit and authorize John Wilkerson and his employees, agents, and personnel who are acting on behalf of his endeavors to use my photograph/video/voice or other likeness for purposes related to his websites, writing, and promotion, including publicity, marketing, and promotion of and its various programs. I understand my photograph/video/voice or likeness may be copied and distributed by means of various media, including video presentations, television, news bulletins, mail-outs, billboards or signs, brochures, placement on websites, or newspapers.. et cetera.
I understand that, although all reasonable efforts will be made to use my photograph/video/voice or likeness in accordance with standards of good judgment, Mr. Wilkerson cannot warranty or guarantee that any further dissemination of my photograph or likeness will be subject to his supervision or control. Accordingly, I release Mr. Wilkerson from any and all liability related to dissemination of my photograph/video/voice or likeness.
I have read this Release for Image Use and understand its contents.
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 parent(s) and/or legal guardian(s) of the minor participant named below agree:
1. 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 partial 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.
2. 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.
3. I/We HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the martial arts facility used by the participant, including it 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 to kin For any and all claims, demands, losses or damages and any claims or demands therefore on account of any injury, including but not limited to the death of the participant or damage to property, arising out of or relating to the events(s) caused alleged to be caused in whole or in part by the negligence of the releasee or otherwise.
4. 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.
5. 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, notwithstanding continue in full legal force and effect.
I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.