HOSTED BY:

COLORADO BUDOKAN

@

Colorado School of Mines

Volk Gymnasium

Wrestling Room

1400 Illinois Street

Golden, CO

KATA SEMINAR

= = = = = = GOLD MEDALS = = = = = = 2003 Jr. World Championship

2003 14th Jr. Pan American Championship 2004 USANKF National Championship

2006 17th Jr. Pan American Championship 2007 18th Jr. Pan American Karate Championship

2009 USANKF National Championship 2010 USANKF National Championship

2011 USANKF North American Championship 2011 USANKF National Championship

= = = = = = SILVER MEDALS = = = = = =

2005 USANKF National Championship 2006 USANKF National Championship

2006 20th Pan Am Karate Championship 2007 USANKF National Championship

2008 USA Open 2008 USANKF National Championship

= = = = = = BRONZE MEDALS = = = = = =

2002 13th Jr. Pan American Championship 2006 5th World University Karate Championship 2007 21st Pan American Karate Championship

2009 USA Open 2009 North America Cup 2010 North America Cup

William Vassar Louie Bradford

WKF, World, Pan American and National

Champion

2011 US Nationals Gold Medalist for the Men's

Advance Elite Kata Competition

2011 North American Cup Gold Medalist

December 13, 2014

1 - 4 pm

Kata Seminar Registration

Name _____________________________________________________ Sensei __________________________________________

Seminar Fee $35

Method of Payment: Cash _________ Check#__________

Credit/Debit Card__________ Please circle: Visa MC Discover

Card #____________________________________ Exp. ________ CVC________

Cardholder Name___________________________________________________

RELEASE AGREEMENT - READ CAREFULLY BEFORE SIGNING

I understand that karate is a very dangerous martial art involving forceful physical contact, that it is likely to incite aggressive behavior which is beyond the control of Colorado Budokan ("CB") and Colorado School of Mines (“CSM”), that severe injuries or death may result from my participation in the activities of this martial art, and I fully and knowingly accept these risks. I therefore release CB, CSM, their officers, agents, and employees, and any and all volunteers or paid instructors from any and all liability, now and in the future, arising from or in connection with the activities of and concerning CB and CSM. Further, I understand that any medical treatment given to me will be of a first aid treatment type only. Further, I certify that I am physically and emotionally sound, have medical approval to proceed with rigorous exercise, including physical contact, and assume full responsibility for my own well-being. I hereby waive any and all rights I may have to bring any legal action against CB, CSM, CB member, CSM student, CSM representative, or anyone else in connection with any injury I may suffer as a result of my participation in Kata Seminar (“KS”). Further, I release CB and CSM from any and all liability, which would, could, or might arise from any act of omission on its part in connection with CB, CSM, and KS.. If under 18 years of age, the approval of a parent or legal guardian is required. I have read and understood the above.

___________________________________________________________ _____________________________________ (Signature) (Date)

___________________________________________________________ _____________________________________ (Signature of Parent/Guardian) (Date)

Send Registration/ReleaseAgreement and CSM Waiver of Liability with payment to:

Colorado Budokan 3547 South Monaco Parkway

Denver, Colorado 80237

Participants under the age of 18 This form must be submitted with individual registration form.

Waiver of Liability, Assumption of Risk and Indemnification Agreement for Use of

Colorado School of Mines Athletics Facilities (for children of faculty, staff and students, and CSM students under the age of 18)

1. The undersigned person (hereinafter referred to as “User”) wishes to access and use the Colorado School of Mines

Athletics (hereinafter “Facility”) facilities, activities and programs.

2. In consideration of CSM permitting User to access and use the Facility, the undersigned Parent or Guardian agrees

to hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE the Colorado School of Mines,

and its Board of Trustees, officers, employees, agents, and representatives, from any and all liability for any and all

damages, losses or injuries to persons or property, which arise out of, occur during or result from User’s use of the

Facility.

3. To the best of my knowledge, I am not aware of any physical disability or health-related reasons or problems that

would preclude or restrict my child’s use of the Facility. I am fully aware of the risks and hazards associated with

my child’s participation in recreation and exercise activities, and I understand that certain, inherent risks cannot be

eliminated regardless of the care taken to avoid injuries. I understand that specific risks vary depending on the level

and nature of the activity, and can range from minor personal injuries such as scratches, bruises, and sprains, to

major injuries such as eye injuries and back or joint injuries, or catastrophic injuries resulting in paralysis or death. I

understand that use of the Facility is purely voluntary, and notwithstanding the risk of injury to my child or his or

her property, I consent to my child’s use of the Facility, and I VOLUNTARILY ASSUME FULL

RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE, AND PERSONAL INJURY,

INCLUDING DEATH, that may be sustained by my child as a result of his or her use of the Facility and

participation in Facility activities and programs.

4. My child has sufficient health insurance coverage to provide for and pay any medical expenses that may directly or

indirectly result from his or her use of the Facility and/or participation in Facility activities and programs. I

understand that the Colorado School of Mines does not take responsibility for the payment of any such medical

expenses.

5. I agree to INDEMNIFY AND HOLD HARMLESS the Colorado School of Mines, its Board of Trustees, officers,

employees, agents, and representatives from any and all claims, actions, costs, expenses, damages and liabilities,

including attorney’s fees, that may be incurred as a result of my child’s use of the Facility and/or participation in

Facility activities and programs.

6. I understand that this Agreement is intended to be as broad and inclusive as is permitted by the law of the State of

Colorado, and that if any portion hereof is held invalid, it is agreed that the remaining terms shall continue in full

legal force and effect.

7. Nothing in this Agreement shall be construed to waive, limit, or otherwise modify any governmental immunity that

may be available to the State of Colorado, Colorado School of Mines, its Board of Trustees, officers, employees,

agents and representatives under the Colorado Governmental Immunity Act, Colorado Revised Statutes § 24-10-

101, et seq.

8. By my signature below, I acknowledge and represent that I have read this WAIVER OF LIABILITY,

ASSUMPTION OF RISK AND INDEMNIFICATION AGREEMENT, fully understand and accept its terms, and

sign it voluntarily.

__________________________________

User’s Name (Print)

__________________________________ __________________

User’s Signature Date

__________________________________ __________________

Signature of User’s Parent or Guardian Date

Participants age 18 and older This form must be submitted with individual registration form.

Waiver of Liability, Assumption of Risk and Indemnification Agreement for Use of

Colorado School of Mines Athletics Facilities (for adult students, faculty, staff and guests)

1. I, the undersigned person, wish to access and use the Colorado School of Mines Athletics (hereinafter “Facility”)

facilities, activities and programs.

2. In consideration of being permitted to access and use the Facility, I, for myself and on behalf of my heirs, personal

representatives and assigns, do hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE the

Colorado School of Mines, and its Board of Trustees, officers, employees, agents, and representatives, from any and

all liability for any and all damages, losses or injuries to persons or property, which arise out of, occur during or

result from my use of the Facility.

3. To the best of my knowledge, I am not aware of any physical disability or health-related reasons or problems that

would preclude or restrict my use of the Facility. I am fully aware of the risks and hazards associated with

participating in recreation and exercise activities, and I understand that certain, inherent risks cannot be eliminated

regardless of the care taken to avoid injuries. I understand that specific risks vary depending on the level and nature

of the activity, and can range from minor personal injuries such as scratches, bruises, and sprains, to major injuries

such as eye injuries and back or joint injuries, or catastrophic injuries resulting in paralysis or death. I understand

that my use of the Facility is purely voluntary, and notwithstanding the risk of injury to my person or property, I

elect to use the Facility, and I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS,

PROPERTY DAMAGE, AND PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me as a

result of my use of the Facility and participation in Facility activities and programs.

4. I have sufficient health insurance coverage to provide for and pay any medical expenses that may directly or

indirectly result from my use of Facility and/or participation in Facility activities and programs. I understand that the

Colorado School of Mines does not take responsibility for the payment of any such medical expenses.

5. I agree to INDEMNIFY AND HOLD HARMLESS the Colorado School of Mines, its Board of Trustees, officers,

employees, agents, and representatives from any and all claims, actions, costs, expenses, damages and liabilities,

including attorney’s fees, that may be incurred as a result of my use of the Facility and/or participation in Facility

activities and programs.

6. I understand that this Agreement is intended to be as broad and inclusive as is permitted by the law of the State of

Colorado, and that if any portion hereof is held invalid, it is agreed that the remaining terms shall continue in full

legal force and effect.

7. Nothing in this Agreement shall be construed to waive, limit, or otherwise modify any governmental immunity that

may be available to the State of Colorado, Colorado School of Mines, its Board of Trustees, officers, employees,

agents and representatives under the Colorado Governmental Immunity Act, Colorado Revised Statutes § 24-10-

101, et seq.

8. If employed by CSM, I understand and agree that my use of the Facility and/or participation in Facility activities and

programs is strictly voluntary and is not within the course and scope of my employment with CSM. Therefore, any

injury I sustain while using the Facility or participating in Facility activities and programs will not be covered under

CSM’s Workers’ Compensation program.

9. By my signature below, I acknowledge and represent that I have read this WAIVER OF LIABILITY,

ASSUMPTION OF RISK AND INDEMNIFICATION AGREEMENT, fully understand and accept its terms, and

sign it voluntarily.

________________________________________

User’s Name (Print)

________________________________________ _______________________

User’s Signature Date

Directions to Colorado School of Mines – Volk Gymnasium

From Denver (via I-70):

West on I-70, pass Kipling, pass Ward Road, take next exit west on Highway 58 (exit 265, marked Golden, Central City, Colorado School of Mines), exit at Washington Avenue, left on Washington Avenue, right on 13th Street, left on Maple. Enter the building - 1st driveway on the left next to the Fieldhouse.

From Denver (via 6th Avenue):

West on 6th Avenue, pass I-70 West exit, pass Colfax, turns into Highway 6, right at the second stop light (19th Street), left on Illinois, left on 13th Street, left on Maple. Enter the building - 1st driveway on the left next to the Fieldhouse.

From Colorado Springs:

North on I-25 to Denver, west on Highway 470 (exit 194 to Grand Junction), pass Highway 285, immediately after the sign marked US 6/6th Avenue, take I-70 west (left 2 lanes), take 6 West/6th Avenue West (left 2 lanes), right at 19th Street (second stop light). left on Illinois. left on 13th Street, left on Maple. Enter the building - 1st driveway on the left next to the Fieldhouse.

From Fort Collins:

South on I-25 to Denver, west on Highway 76 (Exit 216B to Arvada/Grand Junction), west on I-70, pass Kipling, pass Ward Road, take next exit west on Highway 58 (exit 265, marked Golden, Central City, Colorado School of Mines), exit at Washington Avenue, left onto Washington Avenue, right on 13th Street, left on Maple. Enter the building - 1st driveway on the left next to the Fieldhouse.