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MILL BAY SHIDOKAI

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Mill Bay, British Columbia

01. Registrant InformationRegistrants
02. Confirmation & PaymentConfirmation
03. ReceiptReceipt

Conditions of Membership: Your request for membership with Judo BC represents your agreement to abide by the rules, regulations, policies and codes of Judo BC, including but not limited to, the agreement to submit to a criminal records review, upon request.

# of individuals you want to register

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Registrant #1

Are you sure this individual isn’t the following:

Are you a new or renewing member? *Judo Canada # * Lookup I am a new member

I am new to Judo Canada
I am already a member or am renewing my membership
with Judo Canada

First Name *

Last Name *Is your Name incorrectly spelled?

Gender *

Male Female Other

Date of Birth * (YYYY-MM-DD)

/ /

No category for this age.

School Name

Full Mailing Address - Street Address *

Address 2

City *

Province/State *

Country *

Postal Code *

Individual Email * Opt in to receive emails

Home Phone * - International Number

Work Phone - International Number

Visually Impaired *

No Yes

Physical disability *

None Deaf Autistic Other

Indigenous Descent *

No Yes

Please select each option that applies to this member *

Profile Photo

NCCP #

Belt Level *

Region you Reside *

Are any modification required for the individual to participate in judo i.e. parent to provide tips regarding learning differences, helper required due to visually impairment

Citizenship *

Occupation - i.e. secondary school student, university/college student, business person, retired teacher, etc...

Primary Role *

Secondary Role

Tertiary Role

Please list any special skills you would be willing to share i.e accounting, first aid, marketing:

Communication consent - I consent to receive the Judo BC bi-weekly/monthly e-newsletter via email. Your email address will not be shared with any businesses, organizations or individuals. We strongly encourage everyone to opt in to receiving the e-newsletter as it provides the most up to date news and information regarding events, competitions, camp, regional kids festivals & educational opportunities. You can unsubscribe to the e-newsletter at anytime. *

Yes No

I consent to having my mailing address, telephone number & email address published in the Judo BC Black Belt Directory which is available in electronic format to clubs and Yudansha members. *

Yes No Name only Name, club & email address only Other

Parent/Guardian Name #1 *

Parent/Guardian Daytime Phone #1 * - International Number

Parent/Guardian Evening Phone #1 * - International Number

Parent/Guardian Email #1 * Opt in to receive emails

Parent/Guardian Name #2

Parent/Guardian Daytime Phone #2 - International Number

Parent/Guardian Evening Phone #2 - International Number

Parent/Guardian Email #2 Opt in to receive emails

Care Card Number (Personal Health Number) *

Allergies

Medical Conditions (to be report to an EMT in case of emergency)

Recent injuries (within the past 12 months)

Older injuries i.e. concussion in 2020, ACL injury and surgery in 2015

Emergency Contact Name (for minors please list someone other than the parent/guardian(s). In case the parent/guardian(s) is unavailable) *

Emergency Contact Phone Number * - International Number

Emergency Contact relation to participant *

Membership type

Notice: You have reached your maximum number of individual entries for this registrant.

There are no available categories for the age of this registrant.

Add another membership type

Membership type (Judo BC)

Membership type *

Category *

There are no available categories for the age of this registrant.

Membership type (Judo Canada)

Membership type *

Category *

There are no available categories for the age of this registrant.

Waivers

I have read and agree *
RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT Section 1 - Description of Risk (To be executed by Participants who are 19 years of age or older). WARNING! By signing this document you will waive certain legal rights. Please read carefully.

I have read and agree *
RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT Section 2 - Terms and Attestation (To be executed by Participants who are 19 years of age or older). WARNING! By signing this document you will waive certain legal rights. Please read carefully.

I have read and agree *
RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT Section 3 - Release of Liability and Waiver (To be executed by Participants who are 19 years of age or older). WARNING! By signing this document you will waive certain legal rights. Please read carefully.

I have read and agree *
RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT Section 4 - Jurisdiction (To be executed by Participants who are 19 years of age or older). WARNING! By signing this document you will waive certain legal rights. Please read carefully.

I have read and agree *
RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT Section 5 - Acknowledgement (To be executed by Participants who are 19 years of age or older). WARNING! By signing this document you will waive certain legal rights. Please read carefully.Edit*RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT Section 3 - Release of Liability and Waiver (To be executed by Participants who are 19 years of age or older). WARNING! By signing this document you will waive certain legal rights.

I have read and agree *
INFORMED CONSENT AND ASSUMPTION OF RISK AGREEMENT Section 1 (To be executed by the parent/legal guardian of Participants who are under 19 years of age) WARNING! By signing this document you will waive certain legal rights. Please read carefully.

I have read and agree *
INFORMED CONSENT AND ASSUMPTION OF RISK AGREEMENT Section 2 (To be executed by the parent/legal guardian of Participants who are under 19 years of age)

I have read and agree *
INFORMED CONSENT AND ASSUMPTION OF RISK AGREEMENT Sector 3 (To be executed by the parent/legal guardian of Participants who are under 19 years of age) WARNING! By signing this document you will waive certain legal rights. Please read carefully.

I have read and agree *
INFORMED CONSENT AND ASSUMPTION OF RISK AGREEMENT Section 4 (To be executed by the parent/legal guardian of Participants who are under 19 years of age) WARNING! By signing this document you will waive certain legal rights. Please read carefully.

I have read and agree *
INFORMED CONSENT AND ASSUMPTION OF RISK AGREEMENT Section 5 (To be executed by the parent/legal guardian of Participants who are under 19 years of age) WARNING! By signing this document you will waive certain legal rights. Please read carefully.

I have read and agree *
Media Release

Digital signature (type your name exactly as entered above "registrants name") *

Parent/guardian digital signature *

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