DECLARATION OF ACCEPTANCE Participant s Name: D.O.B.: Age: Sex: M F Today's Date: Address: City: Postal Code: Phone #: E-Mail: How did you hear about us? I am physically and mentally able to take the Urban Defensive Tactics, Urban Force Options, and Urban Combat Fitness training sessions offered by Kennedy Tactical Concepts. (PLEASE FILL OUT THE MANDATORY HEALTH QUESTIONNAIRE INCLUDED WITH THIS FORM) I understand and agree that the Urban Defensive Tactics, Urban Force Options, and Urban Combat Fitness training sessions offered by Kennedy Tactical Concepts may involve intense physical training, high levels of cardiovascular activity and simulated violent attacks, with the real risk of injury, including serious injury, disability and death arising from participation in the programs. I further understand and agree that the programs involve working in close physical proximity to, and with physical contact between the participants and the instructors and among the participants themselves. I HAVE READ AND I AGREE TO THE FOLLOWING PROVISIONS, WHICH ARE A LIMITATION OF LEGAL LIABILITY ON THE PART OF KENNEDY TACTICAL CONCEPTS AND WHICH LIMIT MY RIGHTS, INCLUDING THE RIGHT TO COMMENCE AND CONTINUE LEGAL PROCEEDINGS: I hereby release, remise and forever discharge Kennedy Tactical Concepts, its employees, agents, directors, officers, successors, heirs and assigns, from any and all damage, liability, loss or obligation arising from or occurring during my participation in the Urban Defensive Tactics, Urban Force Options, and Urban Combat Fitness training sessions offered by Kennedy Tactical Concepts, including but not limited to: 1. injury, including serious personal injury, disability and death; 2. damage to personal property and effects; 3. loss or theft of personal property; and I understand that the Urban Defensive Tactics, Urban Force Options, and Urban Combat Fitness training sessions offered by Kennedy Tactical Concepts l while conducted with participant safety in mind, and while Kennedy Tactical Concepts and its agents and employees will employ every reasonable precaution to ensure the safety and security of participants, some risk is unavoidable, and Kennedy Tactical Concepts can in no way guarantee my safety or health while I participate in the program, which is inherently dangerous. Kennedy Tactical Concepts recommends the use of protective equipment including (but not limited to) mouth guards, groin protectors and safety goggles to reduce (but not eliminate) the risk of injury, disability or death. Participant s Signature: Date:
MEDICAL QUESTIONNAIRE DOCTOR S INFORMATION Name: Address: City: Province: Postal Code: Phone: EMERGENCY CONTACT (in case of emergency, please notify) Name: Relationship: Address: City: Province: Postal Code: Phone (Home): Phone (Work): Please check the appropriate boxes: Are you over 40 and unaccustomed to regular exercise? Is there any reason (not mentioned above) why strenuous exercise may prove uncomfortable or harmful? If you answered YES to any of the above questions, please state the reason(s) below: Do you have any history of personal medical conditions including (but not limited to): Heart Disease, High Cholesterol, High Blood Pressure, Stroke, Migraine, Asthma, Diabetes, Epilepsy, Cancer, Pneumonia, Joint Problems, Menstrual Disorders, Rheumatic Fever, Angina, Arthritis, Chest Pains, Chronic If you answered YES, please state the condition(s) below, as well as the treatment you are receiving and any medication you are taking: Are you aware of any physical or medical condition which does or may affect your health which you have not already disclosed on this Medical Screeni If you answered YES, please explain: Participant s Signature: Date:
PROMOTIONAL MEDIA USE - PERMISSION I hereby authorize Kennedy Tactical Concepts, its agents, employees, officers and assigns, to take, process, publish, or otherwise use photographs, motion pictures, video images, or other forms of visual reproduction, and voice prints of myself either alone or with others, in any way deemed appropriate by Kennedy Tactical Concepts in the sole and absolute discretion of Kennedy Tactical Concepts without my pre-approval, for recruitment or promotional purposes. Participant s Name: Participant s Signature: Date:
URBAN DEFENSIVE TACTICS INSTRUCTOR QUESTIONNAIRE Do you have any Martial Arts and/or Professional certifications that can be verified? If so, with whom? Are you attached to any other Martial Arts Association, Organization, or Group. If so, with whom? How long have you been training in martial arts? Do you have a criminal record? If so, what were the charges?
URBAN DEFENSIVE TACTICS INSTRUCTOR AGREEMENT On all articles below, please initial next to Yes or No to indicate your selection: (i) Do you understand that all material from Kennedy Tactical Concepts, including the name of business, programs, logo, and merchandise is all property of Kennedy Tactical Concepts and cannot be duplicated or reproduced in any fashion without written consent from T.J. Kennedy. You will be charged with copyright infringement and processed to the full extent of the law, along with any losses associated with the infringement. Do you understand this?: Yes No (ii) Do you understand that if T.J. Kennedy does not feel that you are ready or have not successfully completed all the tests associated with this training certification he will not pass you, but you will have the opportunity to take the course at a later date free of charge until you pass? Do you understand this?: Yes No (iii) Do you understand that you may not produce, sell, manufacture, record, create web pages, post blogs, enter chat rooms, video tape, or produce any media in regards to Kennedy Tactical Concepts without written consent from T.J. Kennedy? Do you understand this?: Yes No (iv) Do you understand that Kennedy Tactical Concepts and T.J. Kennedy will be posting your information on the Kennedy Tactical Concepts web page and will be using photos and videos of you for promotional purposes? Do you understand this?: Yes No (v) Do you understand that if you break any rules and regulations, bring Kennedy Tactical Concepts or T.J. Kennedy or KTC instructors into any danger or bad light you will be removed from all affiliation and terminated from Kennedy Tactical Concepts, your certifications revoked, and you will be barred from ever attending any future courses? Do you understand this?: Yes No (vi) Do you understand that you will not appear on the Radio, News, or any sort of media outlet representing Kennedy Tactical Concepts or T.J. Kennedy without written approval from T.J. Kennedy? Do you understand this?: Yes No (vii) Do you understand that you will not be able to teach Urban Defensive Tactics in any way, shape, or form to anyone if you are released from Kennedy Tactical Concepts or leave of your own free will; and that if you do leave you will no longer be able to use the name, logo, material, or anything in regards to Kennedy Tactical Concepts as long as Kennedy Tactical Concepts is in operation? Do you understand this?: Yes No
Our UDT Instructor Certification Course is broken into 5 modules, divided by topic. Each module is 12 hours, for a combined course total of 60 hours. The modules are as follows: Module 1 Core Concepts Module 2 Clinches, Chokes & Holds Module 3 Urban Ground Fighting Module 4 Edged, Impact & Flexible Weapons Module 5 Handguns & Long Guns Testing Day Demonstrate sufficient Technical, Improvisational, and Instructional ability Required Reading to become certified: The Gift of Fear (Gavin DeBecker), Meditations on Violence (Rory Miller), Left of Bang (Patrick Van Horne & Jason A. Riley). Training Schedule: *Training Schedule A 1 module/month, for 6 months (eg. Sunday 8 AM-8 PM) *Training Schedule B 2 modules/month, for 3 months (eg. Saturday 8 AM-8 PM, Sunday 8 AM-8 PM) *Training Schedule C 5 modules + test in one week, 6 days (eg. Monday-Saturday 8 AM-8 PM) Cost (per person*): $1200 plus 13% HST (monthly plans available) Option 1: 100% payment up front (save $120 CAD) = $1080 CAD plus HST Option 2: 50% down payment ($600 CAD plus HST), 5 monthly payments of $120 CAD plus HST Option 3: 25% down payment ($300 CAD plus HST), 5 monthly payments of $180 CAD plus HST An URBAN DEFENSIVE TACTICS INSTRUCTOR should lead by example, embodying Kennedy Tactical Concepts Mission, Vision & Values. In keeping with this, to maintain your instructor status, you must regularly update your training by re-attending these courses at a minimum of once every three years, at a 50% discount each time. Do you understand this?: Yes No (ix) Do you understand that you must purchase all certified Kennedy Tactical Concepts material and products from Kennedy Tactical Concepts HQ and must not produce any material without first getting approval through HQ? Do you understand this?: Yes No (x) Do you understand that you are responsible for your own liability insurance and that Kennedy Tactical Concepts, or T.J. Kennedy are in no way responsible for any financial obligation to you, your facility, or your students, and that you take full responsibility for any lawsuits, injuries, deaths that might directly or indirectly be associated with teaching and training in Urban Defensive Tactics? Do you understand this?: Yes No
(xi) Do you understand that Kennedy Tactical Concepts or T.J. Kennedy cannot be sued, held responsible, or blamed for any action that was previously mentioned because you understand that Urban Defensive Tactics involve physical contact and should only be taught as a last resort in defence of one s personal safety and others safety, and that you are to train with safety as the top priority? Do you understand this?: Yes No (xii) Do you understand that this document is here to protect Kennedy Tactical Concepts, its business structure, T.J. Kennedy, and Kennedy Tactical Concepts Instructors? Do you understand this?: Yes No (xiii) Do you understand that Urban Defensive Tactics classes must be kept separate from all other classes on your schedule? You are permitted to teach whatever you like, provided that Urban Defensive Tactics is kept separate from it. Do you understand this?: Yes No *All material hereby written is subject to change without notification.* **WARNING: Any breach of this agreement will result in immediate legal action against you if you misuse or abuse this system in any way, shape, or form. You agree that all things are 100% accurate about yourself, and you have full understanding and hold Kennedy Tactical Concepts, T.J. Kennedy, and anything or anyone that has to do with the Kennedy Tactical Concepts NOT LIABLE and understand the risks associated with this legal form.** Name (please print): Signature: Today s Date: