The undersigned hereby gives informed consent to engage/participate in a variety of physical activities. The possibility exists that certain detrimental physiological changes may occur during JUJITSU activity/exercise. These changes could include, but are not limited to heat related illness, abnormal heart beats, abnormal blood pressure, subluxation, strains, sprains, broken bones, unconsciousness and in rare instances, a heart attack. I understand that any activity involving motion and/or height creates the possibility of accidental injuries. Only properly trained and qualified participants under supervised conditions should undertake JUJITSU activities. Participation without proper training and/or conditioning could be dangerous and should not be undertaken. Before participating in any activity, know your limitations, the limitations of your classmates and the limitations of the equipment. I understand that I am not permitted to attempt any maneuver/skill in this JUJITSU class, which has not been covered during class instruction, without the instructor’s permission. If in doubt, always consult your instructor. Avoid landing on head or neck as serious injury, paralysis or death may result.

I hereby acknowledge and certify that:

The instructor has informed me that he/she cannot be omnipresent and observe my every movement. I understand that there are inherent risks associated with any physical activity and recognize it is my responsibility to monitor my individual physical status during an activity. I understand that the ultimate responsibility for my personal safety is mine alone. I have been instructed in the safety guidelines of the JUJITSU Class KIN 101-S and as a responsible adult I hereby agree to abide by them and use good judgment in my class conduct. I do not have any physical/mental limitations or conditions, which would prohibit/impair my/other safety of participation in this JUJITSU course. In the event of a medical problem, I recognize that any medical care that may be required is my personal financial responsibility. The class grading method has been explained to my satisfaction and I understand that my grade will be effected if I do not complete all class requirements. Cheating may result in a failing grade. I am responsible for filing a formal drop notice (before the last day to drop) with the admissions office if I decide to withdraw from this class. Failure to file a formal withdrawal notice may result in a failing grade. After being appraised of the nature of the Kinesiology and Nutritional Science/Martial Arts Program and with full knowledge of the range of consequences, including adverse physical reactions that may happen to those who participate in such programs, I hereby accept the risk associated with participation in this course.

By signing this form, I certify that I have read all of the foregoing, understand it, and am ready to safely participate. I agree to abide by all of the safety guidelines for class participation.

Print Name

Student Signature

Date Signed

Parent Signature (if under 18 years of age)



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