I HEREBY:

_____ 1.	Understand that I have the right and duty to inspect the mats, facilities, and equipment to be used and if I believe that anything is unsafe or beyond my capability I will immediately advise the instructor or supervisor of such condition(s) and refuse to participate.
_____ 2.	Understand that it is my responsibility to consult with a physician prior to and regarding my participation. I represent and warrant that I am physically fit and have no medical condition which would prevent my full participation.
_____ 3.	Acknowledge and understand that I will be voluntarily engaging in activities that involve contact and the risk of serious injury, permanent disability, or death, and may cause severe social or economic losses due to not only my own actions, inactions or negligence, but also to the action, inaction or negligence of others or conditions of the premises or of any equipment used. Further, I acknowledge that there may be other risks not known to me or not reasonably foreseeable at this time.
_____ 4.	Assume all the foregoing risks and accept personal responsibility for the damages following such injury, permanent disability, or death.
_____ 5.	Release from, waive and discharge all actions, claims, or demands that I, my assignees, heirs, distributees, guardians, and legal representatives now have or hereafter have for damage or losses on account of injury, including permanent disability and death or damage to property, caused or alleged to be caused in whole or in part by the negligence or other acts of Shanti Jujitsu Dojo and/or Shanti Yoga Center, its agents, owners, officers, directors, instructors, sponsors, and other participants, their parents, guardian(s), supervisors and instructors, and the owners, lessors, and lessees of the premises as a result of my participation in any Shanti Jujitsu Dojo and/or Shanti Yoga Center activities. I hereby agree and covenant not to make a claim against, sue or attach the property of Shanti Jujitsu Dojo and/or Shanti Yoga Center or any of its affiliated organizations or above mentioned parties.
_____ 6.	Parent(s) or legal guardian(s) of minor participants (age 17 and below) additionally agree that to instruct the minor participant to the above warnings and conditions and their ramifications, and consent to the minor's participation.

I HAVE CAREFULLY READ THE ABOVE WAIVER AND RELEASE OF LIABILITY AND FULLY UNDERSTAND THAT I GIVE UP SUBSTANTIAL RIGHTS BY SIGNING IT AND I DO SIGN IT VOLUNTARILY. I AGREE TO PARTICIPATE KNOWING THE RISKS AND CONDITIONS INVOLVED AND DO SO ENTIRELY ON MY OWN FREE WILL.

Participant:	_______________________________
Signature:	_______________________________	Date:	_____________
Parent/Guardian:	_______________________________
Signature:	_______________________________	Date:	_____________

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