World Kickboxing Association

(To be completed and signed by all parents/guardians; where divorced or separated, parent/guardian with legal custody must sign.)

Consent and Release from Liability Certificate: Under 18 Years Old

Parental/Guardian Consent, Acknowledgement and Release

A. I/we attest that I am/we are the parent(s) or legal guardian(s) of *
B. I/we hereby give consent for our child/ward to participate in combat sports, as sanctioned and officiated by the World Kickboxing Association USA (WKA USA) and Combat Sports League (CSL) and its associates and agents.
C. I/we know of and acknowledge that my child/ward knows of the risks involved in athletic participation, understand that serious injury and even death is possible in such participation and choose to accept any and all responsibility for his/her safety and welfare while participating in athletics. With full understanding of the risks involved, I/we release and hold harmless my child’s/ward’s school, the schools against which it competes, the competitor, the contest officials, WKA USA, and CSL and any and all responsibility and liability for any injury or claim resulting from such athletic participation and agree to take no action against the WKA USA and CSL because any accident or mishap involving the athletic participation of my child/ward. I authorize emergency medical treatment for my child/ward should the need arise for such treatment while my child/ward is under the supervision of the WKA USA and CSL . I/we further hereby authorize the use or disclosure of my child’s/ward’s individually identifiable health information should treatment for illness or injury become necessary. I/we consent to the disclosure, by my child’s/ward’s to the WKA USA/CSL, upon its request, of all records relevant to his/her athletic eligibility including, but not limited to, his/her records relating to academic standing, age, discipline, residence, and physical fitness. I/we grant the released parties the right to photograph and/or videotape my child/ward and further to use said child’s /ward’s name, face, likeness, voice, and appearance in connection with exhibitions, publicity, advertising, promotional, and commercial materials without reservation or limitation. The released parties, however, are under no obligation to exercise said rights herein.
D. I/we understand that the authorizations and rights granted herein are voluntary and that I/we may revoke any or all of htem at any time by submitting said revocation in writing to the WKA USA and CSL. By doing so, however, I/we understand that my/or child/ward will no longer be eligible for participation in WKA USA and CSL activities.
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