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LIABILITY WAIVER FORM

Student First Name *

Student Last Name *

Student Date of Birth *

Parents First Name (IF UNDER 18)

Parents Last Name (IF UNDER 18)

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Address

Street Address *

City *

State *

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Postal Code *

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Emergency Contact 1 Name *

Emergency Contact 1 Phone *

Emergency Contact 1 Relation *

Emergency Contact 2 Name

Emergency Contact 2 Phone

Emergency Contact 2 Relation

To the best of my knowledge, I am in good physical conditions and fully able to participate in this course. I am fully aware of the risks and hazards connected with the participation in all martial arts based activities, including physical injury or even death, and hereby elect to voluntary, participate in said events, knowing the associated physical activity may be hazardous to me and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OR LOSS, PROPERTY DAMAGE, OR PERSONAL INJURY, INCLUDING DEATH THAT MAY BE SUSTAINED BY ME, OR LOSS OR DAMAGE TO PROPERTY OWNED BY ME, AS A RESULT OF PARTICAPATION IN THIS COURSE. I FURTHER CERTIFY THAT I AM AT LEAST 18 YEARS OF AGE. IF UNDER 18, MY PARENT/GUARDIAN IS THE BELOW SIGNED. I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE, Alpha Martial Arts Academy, M. Adam Saeed, Rhonda McCoy, their officers, agents or employees (herein referred to as RELEASEES) from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me or to any property belonging to me, while participating in physical activity or while on or upon the premises where the event is being conducted. It is my expressed intent that this release and hold harmless agreement shall bind the members of my family and spouse, if I am alive and my heirs, assigns and personal representative if I am deceased, and shall be deemed as a RELEASE, WAIVE, DISCHARGE TO SUE the above named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be constructed in accordance with the laws of the State of Florida. In signing this release, I acknowledge and represent that: I HAVE READ THE FOREGOING WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT, UNDERSTAND IT AND SIGN IT VOLUNTARILY as my own free act and deed; no oral representation, statements or inducements, apart from the foregoing written agreements have been made; and I EXECUTE THIS RELEASE FOR FULL, ADEQUATE AND COMPLETE CONSIDERATION FULLY INTENDING TO BE BOUND BY SAME. I have read and agree to the liability statement above.

I AGREE

Parent Signature (IF UNDER 18)

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Student Signature *

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Date *

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