Participant Verification

Participant File Number

Full Legal Name

Email Address

Participant Information Update

Since completing your Participant Information & Safety Declaration, has any of your medical, physical, emotional, accessibility or emergency-contact information changed?

No, my information remains current.Yes, my information has changed.

If your information has changed, please describe the changes below.

I understand that Huronia Goju-Ryu may contact me for additional information and may require further review before allowing me to participate.

Acknowledgement of Risk

I understand that participation in the Protective Response Certification Program (PRCP) involves physical activity, controlled interpersonal contact, stress-based training, movement drills, defensive response exercises, stabilization exercises, scenario-based training and other activities that may involve inherent risk.

I acknowledge that these activities may result in:

• physical injury;

• emotional stress;

• sprains or strains;

• slips or falls;

• bruising;

• fatigue;

• aggravation of pre-existing conditions; or

• other unforeseen injury.

I understand that no training environment can eliminate all risk.

I have read and understand the Acknowledgement of Risk.

Assumption of Responsibility

I voluntarily choose to participate in PRCP training and accept responsibility for my participation.

I agree to:

• train within my personal limits;

• communicate injuries, discomfort or concerns immediately;

• follow instructor directions;

• respect all safety protocols;

• avoid reckless or aggressive behaviour; and

• act professionally during all training activities.

I understand that I am responsible for monitoring my own physical and emotional condition during training.

I have read and accept the Assumption of Responsibility.

Medical Acknowledgement

I confirm that one of the following applies:

I am physically and mentally capable of participating.I have disclosed all relevant medical conditions, limitations and accommodation requirements.

I understand that PRCP instructors are not medical professionals and that I am responsible for obtaining medical advice regarding my participation when necessary.

I have read and understand the Medical Acknowledgement.

Release of Liability

In consideration for being permitted to participate in PRCP training, I release and discharge:

• Huronia Goju-Ryu;

• PRCP instructors;

• assistant instructors;

• volunteers;

• training partners;

• property owners;

• facility operators;

• event organizers; and

• associated personnel

from liability, claims, demands, actions or causes of action arising from my participation in PRCP training activities, except where prohibited by law.

This includes claims relating to:

• personal injury;

• property damage;

• emotional distress; or

• other losses resulting from participation.

I have read and understand the Release of Liability.

Training Environment Acknowledgement

I understand that PRCP training may occur:

• indoors;

• outdoors;

• in parks;

• in community spaces;

• in gyms;

• in rented facilities; or

• in portable or temporary training environments.

I accept the ordinary environmental risks associated with the location in which my training is conducted.

I have read and understand the Training Environment Acknowledgement.

Contact Training Acknowledgement

I understand that PRCP training may involve:

• controlled physical contact;

• stabilization drills;

• movement drills;

• verbal-pressure drills;

• fatigue-based exercises; and

• controlled scenario training.

I understand that contact training is conducted for educational, defensive and safety-related purposes.

I have read and understand the Contact Training Acknowledgement.

Equipment Acknowledgement

Some PRCP levels or training activities may involve:

• training restraints;

• training batons;

• protective pads; or

• other operational training tools.

I understand that:

• training equipment is not a substitute for judgment;

• force is a last resort;

• equipment may only be used as directed by an instructor; and

• any misuse of PRCP training or equipment outside the program is solely my responsibility.

I have read and understand the Equipment Acknowledgement.

Code of Conduct

I agree:

• to maintain professionalism;

• to avoid reckless behaviour;

• to respect instructors and participants;

• to avoid ego-driven or confrontational conduct; and

• to follow all safety directions immediately.

I understand that an instructor may restrict or end my participation because of:

• unsafe behaviour;

• aggression;

• intoxication or impairment;

• harassment;

• refusal to follow instructions; or

• conduct considered unsafe, disruptive or inappropriate.

I understand that removal from training may occur without a refund where appropriate.

I agree to follow the PRCP Code of Conduct.

Photography and Media Consent

Photographs or video recordings may occasionally be taken during PRCP training for educational, promotional, website or social-media purposes.

Please select one:

Yes, I consent to Huronia Goju-Ryu and PRCP using photographs or video recordings in which I may appear.No, I do not consent to photographs or video recordings in which I may appear being used for promotional or public purposes.

Declining media consent will not affect your eligibility to participate in PRCP training.

No Guarantee Acknowledgement

I understand that participation in PRCP does not guarantee:

• personal safety;

• employment;

• certification or recognition by an outside organization;

• operational competency outside the training environment; or

• success in a real-world confrontation.

I have read and understand the No Guarantee Acknowledgement.

Lawful Use Acknowledgement

I understand that:

• PRCP training is intended for lawful defensive, protective and professional purposes only;

• I remain responsible for ensuring that my actions comply with applicable law;

• misuse of PRCP techniques, concepts or equipment is solely my responsibility; and

• Huronia Goju-Ryu and PRCP do not authorize unlawful violence, punishment, retaliation or misconduct.

I have read and agree to the Lawful Use Acknowledgement.

Final Participant Declaration

Before signing, please confirm each statement.

I have read this agreement in full.

I understand the nature of the activities involved in PRCP practical training.

I have had the opportunity to ask questions before signing.

I am entering into this agreement voluntarily.

The information I have provided is true, accurate and complete.

I agree to notify Huronia Goju-Ryu if my condition or information changes before training.

I agree to follow all instructor directions, safety procedures and participant requirements.

I understand that submitting this form does not prevent an instructor from modifying, restricting or ending my participation for safety reasons.

I intend my electronic signature to have the same effect as my handwritten signature.

Electronic Signature

Type Your Full Legal Name

Date Signed

By submitting this form, I confirm that the typed name above is my electronic signature and that I voluntarily agree to the terms of this agreement.

Your agreement must be received and reviewed before you may participate in PRCP practical training.