TOKUGAWA JUDO CLUB

DÉGAGEMENT DE RESPONSABILITÉ

Je connais les risques associés à la pratique du judo, dont des blessures, un décès, des dommages matériels, des dépenses et pertes associées, incluant une perte de revenu. Ces risques incluent toute négligence de la part de Judo Alberta et ses administrateurs, dirigeants, membres du personnel, officiels, clubs membres et bénévoles, ainsi que Judo Canada, les autres participants et les propriétaires des lieux où ont lieu les activités. J'accepte librement et assume entièrement tous les risques et la possibilité de blessure, décès, dommages matériels, dépenses et pertes associées, incluant une perte de revenu.

DÉGAGEMENT DE RESPONSABILITÉ, LIBÉRATION DE RÉCLAMATION ET CONVENTION D'INDEMNISATION

Compte tenu de l'acceptation de Judo Alberta concernant ma demande de participation aux activités de judo, j'accepte de :

1. Renoncer à toute revendication future contre Judo Alberta et ses administrateurs, dirigeants, membres du personnel, officiels, clubs membres et bénévoles, ainsi que Judo Canada, les autres participants et les propriétaires des lieux où ont lieu les activités.

2. Libérer Judo Alberta et ses administrateurs, dirigeants, membres du personnel, officiels, clubs membres et bénévoles, ainsi que Judo Canada, les autres participants et les propriétaires des lieux où ont lieu les activités de toute responsabilité pour les blessures, décès, dommages matériels, dépenses et pertes associées, incluant une perte de revenu, pouvant survenir suite à ma participation à cette activité pour quelque raison que ce soit, incluant la négligence, une rupture de contrat ou un bris de tout devoir de diligence.

3. Libérer de tout préjudice et indemniser Judo Alberta et ses administrateurs, dirigeants, membres du personnel, officiels, clubs membres et bénévoles, ainsi que Judo Canada, les autres participants et les propriétaires des lieux où ont lieu les activités de toute responsabilité par rapport à tout dommage matériel ou tout préjudice corporel à un tiers parti suite à ma participation à cette activité.

4. Autoriser l'utilisation de mon nom, mon image photographique et toute information personnelle pertinente à la promotion du judo dans les médias, les publications et sites Web liés au judo et pour les associations régulatrices de judo lorsque Judo Alberta le juge opportun.

PIPEDA Agreement

1. The personal information you provide to your Judo Club is collected under PIPEDA (Personal Information Protection and Electronic Documents Act) Privacy Bill for Canada. It is used to determine eligibility for competitive and recreational opportunities, age-related events, class placement, facilitate enrolment, administer and evaluate programs/courses of benefit to athletes, coaches, Board Members, volunteers and referees, and for insurance and statistical purposes. From time to time, personal information may be submitted to major funding bodies to verify registration and meet funding requirements.

2. Member clubs of Judo Alberta collect information from their members when they register to take part in a Judo program. Information is also collected from Board Members, volunteers, coaches and referees in order that the members can be registered with Judo Alberta and Judo Canada. Registration information required by these National Governing Body for Judo may include: name, age, birth date, address, gender, emergency contact information, competitive level attained and citizenship information.

3. Your club’s Privacy Officer, as well as the Privacy Officer for Judo Alberta, are responsible for your personal information and the personal information concerning any minor children. They ensure that all personal information is handled in a confidential manner and all reasonable precautions are taken to avoid loss, theft or unauthorized access, disclosure, copying, use or modification. Any requests to view your personal information should be made in writing to your club Privacy Officer or the Judo Alberta board appointed provincial Privacy Officer to 11759 Groat Road, Edmonton, AB T5M 3K6. The Judo Alberta Privacy Officer contact information will be posted at www.judoalberta.com in accordance with required notification procedures.

Please complete and sign the following form, indicating that you allow the transmission of personal information from the Alberta clubs to the Judo Alberta office, and the subsequent transmittal of personal information as indicated in Paragraph 1 & 2 of this document. Failure to submit this form will constitute denial of membership from Judo Alberta.

Image and Information Release Form

Members of Judo Alberta may have their image, likeness, name (excluding personal address, phone, fax number, and/or email address), province, city/town, and club, as well as rank within Canada used in publications and on the internet by JUDO ALBERTA as well as its agents and sponsors from time to time. When signing this form, athletes, volunteers, coaches, referees and, in the case of minors, their parent/guardian, agree that they have the authority to provide this authorization/approval to JUDO ALBERTA. A facsimile, a scanned and emailed copy, or a photocopy of this form shall be deemed to constitute an original signed document.

1. I allow the use of personal information as outlined above, and image in JUDO ALBERTA and Club Media, including newsletter, website, poster, brochure, video, sponsorship packages.

YES ? (If yes, please sign and date the following form)

NO ? (If no, please indicate in question 2.0 if there are any media in which your, or your child’s image, name or information may NOT appear.)

2. This is a list of the media in which a likeness or information might appear. Please check all media which you DO NOT permit:

2.1 JUDO ALBERTA and/or Club Newsletter, including competition results, stories and games from athletes ????

2.2 JUDO ALBERTA and/or Club Website, including event celebrations and activities that take place in the province ????

2.3 JUDO ALBERTA and/or Club Poster ????

2.4 JUDO ALBERTA and/or Club Brochure ????

2.5 JUDO ALBERTA and/or Club Video ????

2.6 JUDO ALBERTA and/or Club Sponsor Package ????

If Photographs of the athlete are provided to JUDO ALBERTA or to your club, please send each photograph together with the photographer’s express written permission for JUDO ALBERTA or your club to use the photograph(s) on the internet, in publications related to Judo, and in sponsorship materials for Judo.

Failure to submit this form will constitute denial of membership from Judo Alberta.

NOTICE: This is a legal document which must be properly completed and signed or your entry will not be accepted. PLEASE READ CAREFULLY. It affects your rights. If you do not understand it, obtain legal advice before agreeing.

RELEASE, INDEMNITY. WARRANTY. AND ASSUMPTION OF RISK

IN CONSIDERATION OF the acceptance of the entry of __registrant______________________________________ (hereinafter referred to as "the said child") to compete in and/or being permitted to participate in JUDO (hereinafter referred to as "this event"), I/We for myself/ourselves and for and on behalf of the said child hereby release, remise and forever discharge, and agree to indemnify and save harmless the Alberta Kodokan Black Belt Association, Tokugawa Judo Club, the organizers of this event, their respective officers, executives, directors, officials, agents, servants and representatives (hereinafter referred to as "the Releasees") from and against all claims, actions, costs, expenses and demands in respect of death, injury, loss or damage to the person or property of the said child, or myself/ourselves, howsoever caused, arising out of or in connection with the said child competing or participating in this event and notwithstanding that the same may have been caused by, contributed to or occasioned by the negligence, breach of contract, breach of a common duty of care as an occupier of premises, or otherwise, of or by the Releasees or any of them.

I/We agree for myself/ourselves and for and on behalf of the said child to assume all risks, both known and unknown, and all consequences thereof, arising out of or in connection with the said child competing or participating in this event and to adhere to all rules, regulations and conditions of this event.

I/WE CERTIFY THAT:

1. The said child is in good physical condition and has no injury, disease or disability nor has he/she injected or ingested anything that would impair his/her performance or physical condition or increase the likelihood of injury in competing or participating in this event.

2. No physician, nurse, therapist, trainer, coach, manager or other person has advised me/us not to allow the said child to compete or participate in a body contact sport or in this event.

3. I/We am/are familiar with the sport of Judo and the nature of a Judo contest. I/we am/are aware that there is a high risk of injury by the very nature of the sport.

4. We are the father and mother of the said child or the Guardian(s) of the said child and the only person(s) lawfully entitled to act for and on behalf of the said child.

THIS DOCUMENT SHALL BE BINDING UPON THE SAID CHILD, MYSELF/OURSELVES, THE HEIRS, EXECUTORS, ADMINISTRATORS, ASSIGNS AND PERSONAL REPRESENTATIVES OF EACH OF US AND THE SAID CHILD.

I/We have read this document and I/we understand it fully.

SIGNATURES:___________________________ __________________________________

PARENT/GUARDIAN PARENT/GUARDIAN

___________________________ __________________________________

PRINT NAME PRINT NAME

_____________________________ _____________________________________

RELATIONSHIP TO CHILD RELATIONSHIP TO CHILD

Instructions: This form is to be completed for all persons under the age of 18 years by the following

persons:

(a) both natural parents of the child if living together.

(b) both natural parents of the child if separated and no court order for custody has been granted.

(c) both natural parents of the child if divorced and a court order grants joint custody.

(d) both the natural parent and adopting parent of the child if married and if an adoption order has been granted.

(e) both adopting parents of the child if an adoption order has been granted.

(f) either the natural mother or natural father of the child if divorced or separated and being the parent who has sole custody of the child by court order.

(g) all guardians of the child whether appointed by court order or who are guardians by law.

(h) the natural mother of the child if the child is illegitimate and no court order has been granted giving custody to anyone else.

NOTICE: This is a legal document which must be properly completed and signed or your entry will

not be accepted. PLEASE READ CAREFULLY. It affects your rights. If you do not understand it, obtain legal advice before signing.

RELEASE, INDEMNITY. WARRANTY,AND ASSUMPTION OF RISK

IN CONSIDERATION OF the acceptance of my entry to compete in and/or my being permitted to

participate in judo (hereinafter referred to as "this event"), I hereby release, remise and forever discharge, and agree to indenmify and save harmless The Alberta Kodokan Black Belt Association , Tokugawa Judo Club, the organizers of this event, their respective officers, executives, directors, officials, agents, servants and representatives (hereinafter referred to as "the Releasees") from and against all claims, actions, costs, expenses and demands in respect of death, injury, loss or damage to my person or property, howsoever caused, arising out of or in connection with my competing or participating in this event and notwithstanding that the same may have been caused by, contributed to or occasioned by the negligence, breach of contract, breach of a common duty of care as an occupier of premises, or otherwise, of or by the Releasees or any of them.

I agree to assume all risks, both known and unknown, and all consequences thereof, arising out of or in connection with my competing or participating in this event. I agree to adhere to all rules, regulations and conditions of this event.

I CERTIFY THAT:

1. I am in good physical condition and I have no injury, disease or disability nor have I injected or ingested anything that would impair my performance or physical condition or increase the likelihood of injury in competing or participating in this event.

2. No physician, nurse, therapist, trainer, coach, manager or other person has advised me not

to compete or participate in a body contact sport or in this event.

3. I am familiar with the sport of Judo and the nature of a Judo contest. I am aware that there

is a high risk of injury by the very nature of the sport.

THIS DOCUMENT SHALL BE BINDING UPON MYSELF, MY HEIRS, EXECUTORS,

ADMINISTRATORS, ASSIGNS AND PERSONAL REPRESENTATIVES.

I have read this document and I understand it fully.