Parent/ Legal Guardian/ Adult Student*
First
Last
Personal Pronouns* Please select all that apply.
Contact Email* Please enter an email where you can receive class notifications, updates, and which, if you join, you will use to access your account with us.
Would you like to add another adult to this waiver?* Would you like to add a child to this waiver?*
Adult 2 Name
First
Last
Personal Pronouns* Please select all that apply.
Contact Email* Please enter an email where you can receive class notifications, updates, and which, if you join, you will use to access your account with us.
Minor Child 1 Please enter the information requested for each participating child.
Child's Name*
First
Last
Personal Pronouns* Please select all that apply.
Would you like to add another child to this waiver?*
Minor Child 2 Child's Name*
First
Last
Personal Pronouns* Please select all that apply.
Would you like to add a third (3) child to this waiver?*
Minor Child 3 Child's Name*
First
Last
Personal Pronouns* Please select all that apply.
Equity and Inclusion* We are actively seeking to create and support truly diverse membership, including but not limited to members of all racial and ethnic backgrounds, all gender identities, all sexual orientations, and any other identity characteristics to strengthen the work and the reach of the organization.
I agree to the Equity and Inclusion policy.
Training Waiver* I, the undersigned, HEREBY WAIVE AND RELEASE, indemnify, hold harmless and forever discharge KSA Martial Academy and its agents, employees, officers, directors, affiliates, successors and assigns, of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages and liabilities, of every kind and nature, whether known or unknown, in law or equity, that I ever had or may have, arising from or in any way related to my participation in any of the events or activities conducted by, on the premises of, or for the benefit of, KSA Martial Academy provided that this waiver of liability does not apply to any acts of gross negligence, or intentional, willful or wanton misconduct.
I have read and agree.
Infectious Disease and Injury Agreements* The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic, and more may be on the rise. Due to the capacity to transmit from person-to-person, the government sets recommendations, guidelines, and some prohibitions which KSA Martial Academy, LLC will observe as issued.
I have read and agree.
Physical Appearance* I am aware of the existence of the risk on our physical appearance to the venue and our participation to the activity of the Organization that may cause injury or illness such as, but not limited to Influenza, MRSA, or COVID-19 that may lead to paralysis or death.
Health Check* I, nor any member(s) of my household, have not experienced symptoms that of fever, fatigue, difficulty in breathing, or dry cough or exhibiting any other symptoms relating to COVID-19 or any communicable disease within the last 14 days.
High Risk Travel* I have not, nor any member(s) of my household, traveled by sea or by air, to high-risk areas, domestically or internationally, within the past 30 days.
High Risk Travel* I did not, nor any member of my household, visit any any area within the United States that was reported to be highly affected by COVID-19 or any other communicable disease, in the last 30 days .
Recent Diagnosis* I have not been, nor any member(s) of my household, diagnosed to be infected of COVID-19 virus within the last 30 days.
CDC Recommendations Agreements* I, and all members of my household, are following all CDC recommended guidelines as much as possible and limiting our exposure to the Coronavirus/COVID-19. or any other communicable disease.
Personal Responsibility* Following the pronouncements above I hereby declare the following:
I am fully and personally responsible for my own, and that of any members of my household, safety and actions while and during our participation and I recognize that we may, in any case, be at risk of contracting COVID-19 or any other communicable diseases..
Waiver* With full knowledge of the risks involved, I hereby release, waive, discharge the Organization, its board, officers, independent contractors, affiliates, employees, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me or any member of my household related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19 or any other communicable disease..
Indemnification* I agree to indemnify, defend, and hold harmless the Organization from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19 or any other communicable disease..
What classes do you want to try out?* Aikido Filipino Kali Hapkido Jeet Kune Do Muay Thai Tae Kwon Do Private Lessons
Emergency Contact*
First Name
Last Name
Acknowledgement* By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old and fully competent to give my consent; That I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation.
Signature* Self (if 18 years or older)/ Parent/ Legal Guardian(s) only
