Aikido Kenkyukai International USA ("AKI USA") COVID19 Waiver and Acknowledgement of Responsibility Form

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First Name *

Last Name *

Child's First Name *

Please answer either Yes or No to the following statements. *

Yes

I have been fully vaccinated and boosted for Covid19.

I have received my first shot and will soon receive my second shot to be fully vaccinated.

I have tested positive for Covid19 and have since tested negative and/or quarantined myself for at least 14 days.

I have tested positive for Covid19 Antibodies and currently have no symptoms.

I have tested negative for Covid19 and/or Covid19 antibodies.

I have not been tested for Covid19 and/or Covid19 antibodies.

I have health conditions that put me at a higher risk for severe reactions and/or death due to Covid19.

I live with or come into regular contact with anyone who is at a higher risk for severe reactions and/or death due to Covid19.

Yes

I have been fully vaccinated and boosted for Covid19.

I have received my first shot and will soon receive my second shot to be fully vaccinated.

I have tested positive for Covid19 and have since tested negative and/or quarantined myself for at least 14 days.

I have tested positive for Covid19 Antibodies and currently have no symptoms.

I have tested negative for Covid19 and/or Covid19 antibodies.

I have not been tested for Covid19 and/or Covid19 antibodies.

I have health conditions that put me at a higher risk for severe reactions and/or death due to Covid19.

I live with or come into regular contact with anyone who is at a higher risk for severe reactions and/or death due to Covid19.

What health conditions do you have that put you at a higher risk for severe reactions and/or death due to Covid19? *

Please confirm your understanding and acceptance of the following statements by checking on their corresponding box. *

I, the above named, understand that training Aikido or any other form of martial arts at AKI USA is a non-essential activity that carries the risk of transmitting or contracting the novel coronavirus known as COVID19, in addition to other communicable diseases.

I, the above named, understand the risks associated with practice and will take the precautions outlined below as required by AKI USA.

I, the above named, understand that contracting COVID19 may lead to illness, permanent or long term injuries, or death of myself and those who I live with or may otherwise come in contact with and that neither I, nor my estate, will hold AKI USA liable should such a situation occur.

I, the above named, understand that violating the precautions outlined in this document and any further guidance is grounds for termination of my membership from AKI USA and/or participation in this seminar.

I, the above named, will wear a mask at all times on premise at the real property known as 2936 W 8th St, Los Angeles, CA 90005 (AKI USA) until otherwise directed.

I, the above named, other than what is explicitly indicated, will not be entering areas not designated for students, nor mat space not dedicated to my persons during classes for which I am present for.

I, the above named, will follow the cleaning protocol set forth by AKI USA, including but not limited to, wiping down surfaces, weapons, and mats with provided disinfectant wipes, solutions, or sprays.

I, the above named, will wash my hands and feet, or use the disinfectants provided on them before I step on the mat.

I, the above named, will not come to the dojo if I feel unwell or have any symptoms (or combination of symptoms) listed here: headache, fever, sore throat, fatigue, cough, congestion, loss of taste, nausea, or diarrhea. If I have any of those symptoms, I will have to be symptom free and have self quarantine for 14 days or test negative for Covid19/test positive for Covid19 Antibodies before being allowed to return to class.

I, the above named, will immediately notify AKI USA via phone or email if I or anyone I have come into contact with have been given a positive diagnosis of COVID19.

I, the above named, hereby acknowledge and agree to follow all policies outlined above and any forthcoming from AKI USA in regards to the health and safety of myself, the instructors, and other members of AKI USA. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I, and anyone I may later come into contact with, may be exposed to or infected by COVID-19 by attending the classes and that such exposure or infection may result in personal injury, illness, permanent disability, and/or death. I understand that the risk of becoming exposed to or infected by COVID-19 at AKI USA may result from the actions, omissions, or negligence of myself and others, including, but not limited to employees, volunteers, and program participants and their families.

I, the above named, voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself and family members/those I may come into contact with (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that may be experienced or incurred in connection with class attendance. I hereby release, covenant not to sue, discharge, and hold harmless AKI USA, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of AKI USA, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any program.

I, the above named, understand that should any of the previous clauses be found unenforceable, only such clause will be considered void, but will not render the rest as such, and the agreement remains in full effect minus the unenforceable clause.

Required

AKI USA COVID19 Waiver and Acknowledgement of Responsibility Form Executed by: *

If you are over 18 years of age, please enter your name below. If you are under 18 years of age, the parent or legal guardian that has completed this form must enter their name.

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