By checking this box, I understand that my credit card will be automatically charged every month. It is my responsibility to contact Sensei Sal at least 5 days in advance if I no longer wish to attend classes, so that my credit card will not be charged.*

Hold Harmless Agreement. I, the undersigned parent or legal guardian of the minor(s) named above, hereby give permission for the minor(s) to participate in all programs, activities, classes, and events operated by Cirincione’s Inc., Karate Kids in America, Shorinkan San Diego, and their affiliates (collectively “Cirincione’s Inc.”).*

I confirm that the minor(s) and/or adult participant is physically able and mentally prepared to participate in the announced activities. In consideration of being permitted to observe, use the facilities and equipment, or participate in any Cirincione’s Inc. program, I acknowledge on behalf of myself and the minor(s) that:*

• I have read and understand this document;

• I have inspected the facilities and equipment and accept them as safe and suitable for their intended purpose;

• I voluntarily agree to all terms.

*

I hereby release, discharge, and hold harmless Cirincione’s Inc., its directors, officers, employees, volunteers, instructors, and affiliates from any and all liability for any loss, damage to property, injury, or death that may occur to the minor(s) or myself, whether caused by negligence or otherwise.*

I agree not to sue Cirincione’s Inc. for any such claims and will indemnify and hold it harmless from any loss, liability, damage, or cost it may incur due to the minor’s or my presence or participation, including claims arising from negligence.*

I assume full responsibility and all risks of bodily injury, death, or property damage related to these activities.Medical Authorization

I authorize Cirincione’s Inc. to act as my agent and consent, on behalf of the minor, to any x-ray examination, anesthetic, medical, dental, surgical procedure, or hospital care deemed advisable by a licensed physician or surgeon under the California Medical Practice Act.*

I understand that Cirincione’s Inc. is not responsible for any costs incurred for medical, surgical, or dental care. I intend this agreement to be as broad and inclusive as permitted by California law. If any portion is held invalid, the remainder shall continue in full force and effect.*