ACTIVITY HEALTH REPORT OF INVESTIGATION(Please read carefully before signing)□ I am pregnant now or am attempting to be-□ I have any diving disorder or decompression□ I take a medicine by the prescription now (a□ I cannot carry out a moderate activity (e.g., I

come pregnant.

The ACTIVITY HEALTH REPORT OF INVESTIGATION (hereinafter referred to as the Report of Investigation) is a statement in which you are informed of some potential risks involved in an Activity
and is intended to confirm that the risks are announced to you. Your signature on the Report ofInvestigation is required for you to participate in an activity.
Please read the Report of Investigation well prior to signing it. It is necessary to fill out all items of
the Report of Investigation to participate in an activity. The Report of Investigation has somequestions concerning your diseases. If you are a minor, a signature by a person in parental authority or guardian is necessary. An activity is an exciting sport, but is simultaneously hard. Insofar as true and correct techniques are used, an activity is a relatively safe sport.
However, dangers increase when it fails to comply with safe procedure. You MUST NOT downplay Physical condition to enjoy an activity safely. An activity is a very dangerous activity depending on physical condition at that time. It is very important that a respiratory system and a
cardiovascular system are healthy, and all internal space do not have abnormality and ishealthy. A person who catches cold now, has a coronary cardiac illness, is congested, is under
epilepsy and severe medical trouble, is alcohol or drugs dependency with a tendency and isunder the influence of alcohol or drugs MUST NOT participate in an activity. Also, a person withasthma, a cardiac illness and other chronic medical condition, and a person receiving medication regularly now, please take counsel with a doctor and an instructor regularly before andafter participation in an activity. Furthermore, you MUST learn from an instructor in Program withrespect to the required technique and instructions in an activity. Using in the wrong way ofequipment and your wrong action MUST give you and others serious obstacle and losses. YouMUST observe and comply with the direction and designation of the instructor even if hell freezes over.
If you have any questions, please examine this Report of Investigation with an instructor once
again before signing.

contraceptive, a malaria-prevention pill are excluded).

□ I have full dentures now.

□

Did you suffer from the following diseases or do you□□suffer from the following diseases now?

□ A stridor is or was caused at the time of asthcise.

□□allergic symptom is caused.

□ma or at the time of the breathing or exer-□ An intense or frequent attack of hay fever or□ I suffer from a cold, sinusitis or bronchitis well.
□ I suffer or suffered from some kind of disease□ I suffer or suffered from pneumothorax.
□ I suffer or suffered from other disease of lung.

□□□□ I have or had a problem of behavior, or men-□□of lung (such as pneumonia).

Or I have been operated on for lung (breast).
tal or psychological problem (such as panic
attack, claustrophobia, agoraphobia).

□ Epilepsy, an attack, or convulsions are caused
or I take a medicine to suppress it.

□ A complex type migraine headache iscaused repeatedly or I take a medicine tosuppress it.

□ I have experienced loss of consciousness orfainted. (I completely or temporarily loseconsciousness).

Questionnaire concerning diseases
The purpose of this questionnaire is to find out if you should be examined by a doctor before
participating in an activity. It is not meant that there is no qualification to make an activity because you answer each following question Yes. It is meant that there is a preexisting condition
that WOULD affect your safety while an activity and you MUST seek the advice of your physician before participating in an activity. Please answer the following questions on your past andpresent medical history with a YES or NO. If you are not sure, please answer YES to ensure safety. In the case of YES, you MUST take counsel with a physician before participating in an activity. In the case of YES, please put a checkmark (レ ) in the box ( ).

□disorder, or had these disorders.

□ Treatment is necessary for dysentery or dehy-□□□□□

cannot walk the distance of approximately 1.6
kilometer within 12 minutes).
I have suffered harm of the head which lost
consciousness in the past five years.
Low back pain is caused repeatedly.
I have been operated on for the hips or backbone.
I have or had diabetes.
I have an aftereffects of surgery of a waist, anarm, a leg, a wound and bone fracture.
I take or took a medicine which controlled theblood pressure including, but not limited to, highblood pressure symptom or the hypotensivedrug.
I have or had a cardiac disease problem.
A heart attack is or was caused.
I have been operated on for Angina or heart oran artery.
I have been operated on for paranasal sinus.
I have a disease of ear or have been operated
on for ear. I have an impairment of hearing oran equilibrium sense obstacle.
I experience or had experienced a disease of
ear repeatedly.
I have or had bleeding or other blood disability.
I suffer or had suffered from hernia.
I have been operated on for the artificial anusof large intestine and the ileum.
I have used drug for amusement or treatment or
have become alcoholism in the past five years.

dration.

□ I have a medical history or health problems not to correspond to the items mentionedabove. (Please write a medical history and symptom.)[Signature]

MPO30/12/2016

ACTIVITY LIABILITY WAIVER(Please read this activity liability waiver carefully before signing)Ithat(hereinafter referred to as "I") fully acknowledge(hereinafter referred to as "the Activity") to be held at theMotobu Genkimura is accompanied by a risk of serious injury or death. I participate the Activity
based on the fully acknowledgement.
Before signing ACTIVITY LIABILITY WAIVER (hereinafter referred to as "the LIABILITY WAIVER"), I
carefully read and fully understand the LIABILITY WAIVER and declared the above without falsehood based on the understanding. I also fully acknowledge that the Activity is accompanied
by injury, death or other damage to me and my family, property, heir or assignee. I choose toparticipate in the Activity based on the acknowledgement.
I fully understand and agree that Motobu Genkimura which instruct me, operation management company, affiliate and subsidiary of Motobu Genkimura, and each employee, officer, representative, contractor or assignee of those companies (hereinafter referred to as "indemnifyingparty") is not responsible for injury, death or other damage (whether consequential or direct) tome and my family, property, heir or assignee as a result of my participating in the Activity or negligence of the parties including the above indemnifying party in any way even if hell freezes over.
In addition, I fully agree that I SHALL bear personally all responsibility for any injury and otherdamage that may occur to me (whether predictable or not) while I participate in the Activity.
Also, I SHALL release and discharge this Program and indemnifying party from all of claim or litigation by me, my family, my heir or my assignee and SHALL not damage indemnifying party.
I also fully understand that the Activity is physically intense action and I need to make considerable efforts to participate. Further in the event of being damaged by heart attack, panic situation, drowning and others, I fully agree that I undertake a risk of injury by the above clear provision and do not to cause indemnifying party to be liable for.
Furthermore, I reach the adulthood and have a qualification to sign this LIABILITY WAIVER or obtain consent based on the documentation of my person in parental authority or guardian.
Also, I fully understand that terms and conditions described herein are agreement and not justan instruction. I sign this form based on my free will with my consent of waiving in my legal rights
under this LIABILITY WAIVER. Furthermore, in the event either provision of this LIABILITY WAIVER
does not have binding force or validity, I fully agree to separate the provision from this LIABILITY
WAIVER. In this case, the remaining provisions SHALL be construed as there not being the provision that may not be enforced.
I fully agree to release and discharge all the above relevant people from all responsibility for a
personal injury, a property damage or a death from tort (whether consequential or direct loss,
and whatever the cause, including such as negligence of the indemnifying party) arising fromthe Activity which I am instructed based on this LIABILITY WAIVER.

I carefully read this LIABILITY WAIVER prior to signing it for me and my heir and understand thesubstance enough.
I also understand the ACTIVITY HEALTH REPORT OF INVESTIGATION. There are no errors in the information with respect to the medical history and health problem as far as I know. If I do not reveal the present or past health condition, I fully agree to take responsibility about the omission ofdescription.
This LIABILITY WAIVER SHALL be governed by and construed in accordance with the laws of Japan.
In the event of any dispute, the Japanese version of this LIABILITY WAIVER SHALL prevail over thisEnglish version.
YearMonthDay

A participant signature
In the case of a minor, signature by person in parental authority or guardianParticipant entry column (please fill it out in the BLOCK STYLE)
Hotel name.

A participant nameDate of birthYear.

MonthDay

AgeAddress〒

Phone number
Emergency contact number

MPO30/12/2016