ASSERT

Today's Date*

Participant/ Student Name*

First Last

How do you prefer to be addressed?

Do you have a nick name, go by your middle name, is there a specific pronunciation of your name? Let us know here.

Personal Pronouns*

Please select all that apply.

She/ Her/ Hers

He/ Him/ His

They/ Them/ Theirs

She/ They

He/ They

Other

Date of Birth*

If "Other" was selected, please list your Personal Pronouns here.

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.

Enter Email Confirm Email

Contact Phone*

Please enter a number we can use to contact you, via phone or text, in case of emergency class cancelations or other important notifications.

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.

We will not tolerate or allow discrimination against any of our members or participants. If there are claims of discrimination, KSA Martial Academy will adhere to a three-step process, consisting of an official investigation into the suit, remediation of the wrongful behavior(s), and a resolution policy. When a claim is brought forth, a third party will be brought in to validate and substantiate the claim. If a claim is found to be groundless or to have been made out of malice, the reporting member will be suspended from membership for no less than one year up to permanent expulsion from 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 understand that the activities that I will participate in are inherently dangerous and may cause serious or grievous injuries, including, but not limited to, bodily injury, damage to personal property, sprains, contusions, abrasions, broken bones, and, in extreme cases, paralysis and/or death. Due to the potential hazards associated with the activities of the program, I/We recognize the importance of following the instructions regarding fitness/martial arts/ self-defense techniques and other rules associated with the program.

On behalf of myself, my heirs, assigns and next of kin, I waive all claims for damages, injuries and death sustained to me or my property, that I may have against the aforementioned released party to such activity.

By this Waiver, I assume any risk, and take full responsibility and waive any claims of personal injury, death or damage to personal property associated with KSA Martial Academy including but not limited to receiving lessons at the facility, using the facility and its equipment, practicing and/or engaging in marital arts or other related activities on and off the premises.

This WAIVER AND RELEASE contains the entire agreement between the parties, and supercedes any prior written or oral agreements between them concerning the subject matter of this WAIVER AND RELEASE. The provisions of this WAIVER AND RELEASE may be waived, altered, amended or repealed, in whole or in part, only upon the prior written consent of all parties.

The provision of this WAIVER AND RELEASE will continue in full force and effect even after the termination of the activities conducted by, on the premises of, or for the benefit of KSA Martial Academy, whether by agreement, by operation of law, or otherwise.

I have read, understand and fully agree to the terms of this WAIVER AND RELEASE. I understand and confirm that by signing this WAIVER AND RELEASE I have given up considerable future legal rights. I have signed this Agreement freely, voluntarily, under no duress or threat of duress, without inducement, promise or guarantee being communicated to me. My signature is proof of my intention to execute a complete and unconditional WAIVER AND RELEASE of all liability to the full extent of the law. I am 18 year of age or older and mentally competent to enter into this waiver.

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.

In consideration of my participation in the foregoing, the undersigned acknowledge and agree to the following:

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 are you enrolling in?*

Free Trial Class Date*

Let us know when you are coming in so that our Instructors will know to expect you.

Second date choice for free trial class.

Emergency Contact*

First Name Last Name

Emergency Contact Phone Number*

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

Comments

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ASSERT Level I Instructor Certification

Assert Open Group Workshop Level 1

ASSERT Simunition

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