INTRODUCTORY PROGRAM FORM
Name of Student: _______________________ Date: ________
Street Address: _________________________________________
City: ______________
State: _________ Zip: _________
Home Phone: _____________
E-mail: ________________
Gender: Male ___ Female ___
Birthdate: ____/____/____
RELEASE OF LIABILITY/WAIVER
The undersigned, ______________________, agrees that the practice and participation in martial arts,
fitness kickboxing, and/or self-defense requires vigorous physical activity and involves the risk of personal injury;
Having
recognized the same, the undersigned hereby acknowledges awareness of the risks therein, and does certify that s/he is physically
capable of performing the same, has not been otherwise informed by a physician or other healthcare provider, and knows of
no restrictions that would prohibit or prevent him/her from participating in the practice and training of these programs.
THEREFORE,
in and as consideration of being permitted to enroll in the practices and training’s of these programs, the undersigned,
intended is legally bound, does assume all risks in connection therewith for any injury, harm, or damage that may occur to
his/her self while engaged, and does fully release and hold harmless, Keven J. Caldwell and Modern Martial Arts Academy, or
any agent, employee, representative, singly and collectively, from any and all claims, liability, damages, or causes of action
or by the undersigned and his/her family, heirs, estate or assigns as the result of any injury, harm or damage sustained at
any time hereafter as a result of his/her participation in the practice and training of the aforementioned programs.
Dated: __________________
Applicants/Guardian’s Signature: ___________________________________
Emergency Contact Person: ________________________ Phone:
______________
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