Indicate any injuries, health problems, or conditions we should be aware of:
Referred By (or how did you hear about us?):
What are your primary goals?
Waiver of Liability, Assumption of Risk, and Indemnity Agreement
In consideration of being permitted to participate in any way in the Martial Arts Classes hereinafter called “Classes”, I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue Nick Masi, First Defense Martial Arts Center, Defense By Design, LLC, designated instructors, guest instructors, students, staff, landlords, property managers, and any and all other parties of liability, from all liability from any and all claims including the negligence, resulting in personal injury, accidents, or illnesses (including death) and property loss arising from, but not limited to, participation in the Classes.
Assumption of Risks: Participation in the Classes carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions 3) catastrophic injuries including paralysis and death.
Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD Nick Masi, First Defense Martial Arts Center, Defense By Design, LLC, designated instructors, guest instructors, students, staff, landlords, property managers, and any and all other parties of liability HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in the Classes and to reimburse them for any such expenses incurred.
Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the laws of the State of Virginia and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.
Consent to be Photographed: I consent that any pictures furnished by me or any pictures or videos taken of me in connection with these classes can be used for publicity, promotion, television, digital or commercial use, and I waive compensation and copyright in regards to thereto.
I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in the Classes. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.
Signed:
Date:
Participant:
Parent or Guardian (If participant is under 18):
Signed:
Parent or Guardian (If participant is under 18):
Signed:
Parent or Guardian (If participant is under 18):
Signed:
Parent or Guardian (If participant is under 18):
Signed:
Parent or Guardian (If participant is under 18):
Signed:
Parent or Guardian (If participant is under 18):
Signed:
Parent or Guardian (If participant is under 18):
Signed:
Parent or Guardian (If participant is under 18):
Signed:
Parent or Guardian (If participant is under 18):
Signed:
Parent or Guardian (If participant is under 18):
Signed: