SUDA International, LLP Presents
CONTROL FACTOR
SEMINAR
Name:
_____________________________________________________________________________
Age: _______ Birthdate: / / Phone: ( )
- .
Address:
Emergency Contact: ____________________________
Emergency Number: ( ) - .
E-Mail: _________________________@____________________
|
REGISTRATION
INFORMATION |
PAYMENT
INFORMATION |
|
QTY COST S.TOTAL Seminar _____ January
29, 2011 $100 _________ STDA Association _____ Membership FREE
FREE TOTAL PAYMENT AMOUNT: $_________ NOTE: Payments are made payable to: SUDA International, LLP |
Name (As it appears on
Credit Card): Payment Type: □ Visa □ Master Card □ Discover □ Check
#_________ □ Money Order Credit Card Billing Address
(NOT P.O. Box): __________________________________________ Card Number:
______________________________ Expiration: __________ |
The signature below
acknowledges your authorization for the charges listed above to be charged to
your credit card, also listed above.
Customer Signature: ____________________________________________________
Printed Name:
______________________________ Date: __________ Location: ___________________
Information obtained on this form, is private and
confidential. Information will ONLY be used for the purpose of processing the
above charges.
MAIL
FORMS AND PAYMENT TO:
SUDA
International, LLP. 2405-B Essington Road PMB 115
Received By: ________________________________________
Print: __________________________________
Date: __________________________
Processed: __________
RELEASE AND INDEMNIFICATION AGREEMENT
This agreement (“Agreement”)
is made and entered into this _______day of _________, 20____, by and between
SUDA International, LLP. An Illinois Limited Liability Partnership (“SUDA”), and ___________________________ (“Participant”).
1.
Representations. I, ________, the Participant, an adult over
the age of eighteen (18) years, am aware that SUDA has professional expertise
and experience in providing various martial arts and fitness training programs,
demonstrations, courses and instruction (collectively, the “Program”), and have
solicited SUDA’s consent to participate in the
Program of my own free will, based on my own desire and interest therein. I
further acknowledge that, through my own knowledge of martial arts and fitness
programs similar to those comprising the Program and also through information
provided to by about the Program by SUDA, I am familiar with the risks inherent
in martial arts and fitness training programs such as those comprising the
Program which involve physical activity, exercise or exertion, and without in
any way limiting the generality of the foregoing, I specifically acknowledge
that (i) the type of martial arts and fitness
training programs comprising the Program may involve physical contact between
myself and other participants in the Program and/or employees or agents of
SUDA, which contact may include, but will not necessarily be limited to
punching, striking, hitting and kicking, and which contact necessarily involves
a risk of bodily injury and/or death and (ii) that the activities comprising
the Program may involve strenuous physical activity, which physical activity
necessarily involves a risk of bodily injury and/or death. I further
acknowledge that after being informed of and reviewing the nature of the
Program, and the risks inherent therein, I am voluntarily choosing to
participate in the Program and to execute this Agreement, that I am voluntarily
assuming any and all risk of bodily injury, illness, disability, physical
condition or limitation that would endanger my health and well-being by virtue
of my participation in the Program, that I now have and will maintain during my
participation in the Program, hospitalization and major medical insurance
coverage that is sufficient to defray any expenses which I may incur for
medical treatment or hospitalization in connection with any injury, illness,
disability, physical condition or limitation that I may sustain during my
participation in the Program, and that SUDA shall bear no responsibility or
have any liability whatsoever to me or any other person or entity claiming
through me or on my behalf for any such medical or hospitalization expenses of
for any other costs, claims, damages, demands, losses, judgments, fees, duties,
charges, liabilities, obligations, suits (whether at law or in equity),
proceedings, or debts of whatever nature or kind, arising out of or in any way
related to my participation in the Program, whether now or hereinafter in
existence.
2.
Release and
Indemnification. I, ________, the Participant, in
consideration of SUDA’s consent to my participation
in the Program, of my own free will and volition, do hereby release, forbear
and waive any and all claims, costs, damages, demands, losses, judgments, fees,
duties, charges, liabilities, obligations, suits (whether at law or in equity),
proceedings, or debts of whatever nature or kind, arising from or otherwise
related to in any way my participation in the Program, whether now or
hereinafter in existence, and do hereby agree to indemnify, defend and hold
SUDA harmless of and from any such claims, costs, damages, demands, losses,
judgments, fees (including but not limited to attorney’s fees, consultants’ fee
or expert witness fees), duties, charges, liabilities, obligations, suits
(whether at law or in equity), proceedings, or debts asserted against SUDA by
me, by any person or entity claiming through me or on my behalf or by virtue of
my participation in the Program.
3.
Scope and
Effect. I, ________, the Participant, agree that this
Agreement is intended to be broadly construed in favor of SUDA to the fullest
extent permitted by the law of the State of
Having carefully and fully reviewed this Agreement, I, the Participant,
hereby knowingly and voluntarily execute this Agreement as of the date first
above named.
______________________________________________
Participant (Adult Signature Required if Under 18
Years)
______________________________________________
Print Name
Please fill out form in its
entirety. Clearly print date and “participant” name. Initial each small line
with the signor’s initials. Sign and print your name at the bottom. Please
include this form for each participant.