TSCL 2 Waiver Liability Form

Athlete Information

*

First Name Last Name

Birth Date

Month Day Year

Address*

Street Address

City State

Zip Code

Contact Number*

Area Code Phone Number

Parent/Guardian Information (if under 18 years of age)

For Minors Only

Guardian's First Name Last Name

Home Number

Guardian Phone Area Code Guardian Phone Number

Athlete’s E-mail

Emergency Information

Emergency Contact's Name

First Name Last Name

Relationship

Phone Number

Area Code Phone Number

Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.*

None

Has the athlete been diagnosed, been treated or exposed to the COVID19 virus or other undetected viruses?*

no

Informed Consent and Acknowledgement

I/We hereby understand and acknowledge that the training, programs and events held by THE SELF-CARE LAB BOXING AND FITNESS CLUB may expose me to many inherent risks, including accidents, injury, illness or even death. I/We assume all risk of injuries associated with participation including, but not limited to, falls, contact with other participants, the effects of the weather, including high heat and/or humidity and all other such risks being known and appreciated by me. I/We hereby acknowledge my responsibility in communicating any physical and psychological concerns that might conflict with participation in activity. I/We acknowledge that I am physically fit and mentally capable of performing the physical activity I choose to participate in. After having read this waiver and knowing these facts, and in consideration of acceptance of my participation and THE SELF-CARE LAB BOXING AND FITNESS CLUB furnishing services to me, I agree, for myself and anyone entitled to act on my behalf, to HOLD HARMLESS, WAIVE AND RELEASE THE SELF-CARE LAB BOXING AND FITNESS CLUB, its officers, agents, employees, organizers, volunteers, representatives and successors from any responsibility, liabilities, demands, or claims of any kind (including death) arising out of my participation in THE SELF-CARE LAB BOXING AND FITNESS CLUB’s training, programs and/or other events. THE SELF-CARE LAB BOXING AND FITNESS CLUB HAS A ZERO TOLERANCE FOR PHYSICAL ALTERCATIONS OUTSIDE OF THE BOXING CLUB. IN THE EVENT AN ATHLETE (YOUTH OR ADULT) ENGAGES IN AN ALTERCATION THAT IS NOT SELF-DEFENSE, THE BOXING MEMBERSHIP WILL BE TERMINATED WITHOUT REFUND AND THE ATHLETE WILL BE UNABLE TO RETURN UNDER ANY CIRCUMSTANCES! I also acknowledge that all forms of child, elder and dependent adult abuse will be reported. This includes but not limited to physical, sexual, emotional, mental, unwillingness or wrongful cruelty.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

For Office Use Only:

Trainer Initials: _______
Referring Agency: ________
First Class Date: _______

OPEN GYM/ GROUP SESSION

YOUTH/ ADULT/ SENIOR

Racial and Ethnic Category of Choice?*

Gender of Choice?*

MaleFemaleN/A

Pronoun of Choice?*

Him/HeShe/HerThem/They

The Self-Care Lab Boxing & Fitness Club 2

www.theselfcarelab.com