Thank You (Waiver)

Participant #1

First Last

Participant #1 Birth date

Participant #2

First Last

Participant #2 Birth date

Parent/Guardian Name (if participant/s under 18)

Parent/Guardian Birth date (if you are participating too)

How did you hear about us?

Friend
Google or internet search
The Empowerment Podcast by Naga

How did you hear about us?

Please let us know which class or workshop you'll be coming to.

Email

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

School and grade (if applicable)

Emergency Contact #1 Name*

Emergency Contact #1 Phone Number*

Relationship

Emergency Contact #2 - Name

Emergency Contact #2 Phone Number

Relationship

I would like to know more about (check all that apply)

1. Do you have any physical or mental disability or challenge that might affect your exercising?*

Yes
No

2. Through your own experience or a doctor’s advice, is there any reason for you to NOT exercise?*

Yes
No

If you answered YES to either of these questions, you should consult your doctor before becoming more physically active.

Is there any other information we should know about you or your child? Tell us anything, we want to get to know you!

Waiver/Release of Liability:*

Agree

In consideration of your acceptance of this form, I for myself, my heirs, executors, administrators and assigns, forever waive, release and discharge any and all rights, claims for damages, unknown, that I may have against NAGA Martial Arts, Self Defense, Community (formerly Tulen Center), their employees, members, or instructors, for any and all injuries in any manner arising or resulting from my participation in classes. I attest and verify that I have full knowledge of the risks involved in any martial arts, self-defense, weights, exercise, and fitness programs and that I freely and voluntarily assume those risks as incident to participation, and that I will assume and pay my own medical and emergency expenses in the event of accident, illness, or other incapacity, regardless of whether I have authorized such expenses, and that I am medically and physically fit and able to participate in classes. I also give consent to NAGA (formerly Tulen Center), its owners, teachers, employees and other students to give minor emergency first aid and/or advice to me. I hereby release claims I have towards them for giving me such treatment. All dues and payments for classes are non-refundable and non-transferable. I give NAGA (formerly Tulen Center) permission to use any photos taken of me for publicity.

Participant Signature

By typing in my name, I acknowledge my signature on the waiver.

Parent or Guardian Signature (if under 18)

By typing in my name, I acknowledge my signature on the waiver.

Yes! I'd like to receive:

Naga Community Upcoming Events & Information

Is there another person in your family you'd like to receive Upcoming Events and Information? If so, please add their email address here: