BILLING AUTHORIZATION
Card Holder Name: ________________________________________________________________________
Card number: ____________________________Expiration date: ________Billing Address ZIP code: _______
Name on the credit card: ____________________________________________________________________
I authorize La Jolla Fencing Academy to bill this credit card $____________________for Summer Camp Fees
Authorized signature: ______________________________________________________________________
Date: _________________Total Fee:__________________________________________________________
The deposit of $100 is non-refundable. In the event that you need to make a cancelation every attempt
will be made to place your child in another camp. If this not possible, funds will be refunded less the
$100 deposit.
If less than 10 people register to the camp it might be canceled, in which case the fees would be
refunded in full.
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT
("Agreement").
In consideration of the opportunity to participate in the fencing activities of La Jolla Fencing Club, I, the undersigned, for myself, my
personal representatives, assigns, heirs and next of kin:
1.I attest that I am physically and mentally fit to participate in the art and activity of fencing and voluntarily assume all risks of loss,
damage or injury that may be sustained while participating in the activities of the La Jolla Fencing Academy
2.I understand that serious accidents can occur during fencing, and that participants can sustain serious personal injuries and/or
property damage as a consequence thereof. Knowing the risks of fencing, I nevertheless hereby agree to assume those risks and to
release and hold harmless all of the persons and entities mentioned above who, through negligence or carelessness or otherwise,
might be liable to me (or my heirs, personal representatives or assigns) for damages.
3. I understand that the La Jolla Fencing Academy, its owners, officers, directors, instructors and members (collectively "La Jolla
Fencing Academy") make no representation regarding the safety, suitability, and compliance with industry standards of the fencing
equipment owned, used, and made available for use to and by the La Jolla Fencing Academy for its members and non-members. I
hereby specifically release and waive the aforementioned parties from any and all liability arising from and in connection with my use of
the La Jolla Fencing Academy equipment.
4.I hereby waive and release any and all claims for damages, for death, personal injury, loss of property or property damage I may
have, or that may subsequently accrue to me, as a result of my participation as a member or a non-member in the activities of the La
Jolla Fencing Academy.
5.I discharge and release in advance the La Jolla Fencing Academy, from any and all liability arising out of or connected in any way
with my participation in the activities of the La Jolla Fencing Academy; including, but not limited to, instruction, training, lessons, bouts
and competitions. My participation is voluntary and done at my own risk.
6.I hereby consent to any emergency medical treatment needed. I understand and agree that medical or other services rendered to me
by, or at the instance of, any of the persons or entities mentioned above is not an admission of liability to provide or to continue to
provide any such services, and is not a waiver by any of the persons or entities mentioned above of any right hereunder.
7.If, despite this Agreement, I or anyone on my behalf makes a claim against any of the releases, I will indemnify, save and hold
harmless each of the releases from any litigation expenses, attorney’s fees, loss, liability, damages, or costs which they may incur as a
result of such claim.
8.I agree to accept and abide by the rules and regulations of the United States Fencing Association (“USFA”) and the USFA San Diego
Division.
9.I agree to conduct myself in a courteous manner while I participate in the activities of the La Jolla Fencing Academy. I agree to treat
other La Jolla Fencing Academy fencers with respect and to observe proper fencing etiquette while on the fencing strip during training,
lessons, and/or competitions.
I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT
THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN MYSELF AND THE LA JOLLA FENCING
ACADEMY AND ITS MEMBERS, AND I HAVE SIGNED IT VOLUNTARILY.
Student/Parent Signature (if Student is younger than 18): ________________________________Date: ______________
Insurance company: __________________________________Policy number: __________________________________
