Eclipse Student Registration Form

  • Student Registration Form

    Fill out the form carefully for registration
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • PAR-Q (Physical Activity Readiness Questionnaire)

    A series of questions about your general physical activity history
  • Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?*
  • Do you have a bone or joint problem that could be made worse by a change in your physical activity?*
  • Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?*
  • In the past month, have you had chest pain when you were not performing any physical activity?*
  • Do you lose your balance because of dizziness or do you ever lose consciousness?*
  • In the past month, have you had chest pain when you were not performing any physical activity?*
  • Do you know of any other reason why you should not engage in physical activity?*

  • Occupational

    General and Medical History
  • Does your occupation require extended periods of sitting?
  • Does your occupation require you to wear shoes with a heel (e.g., dress shoes)?
  • Does your occupation cause you mental stress?
  • Do you partake in any recreational physical activities (golf, skiing, etc.)? (If YES, please explain.)*
  • Do you have any additional hobbies (reading, video games, etc.)? (If YES, please explain.)*
  • Have you ever had any injuries or chronic pain? (If YES, please explain.)*
  • Have you ever had any surgeries? (If YES, please explain.)*
  • Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease,hypertension, high cholesterol, or diabetes? (If YES, please explain.)*
  • Are you currently taking any medication? (If YES, please explain.)*

  • Liability Waiver

  • STUDENT RELEASE OF LIABILITY, WAIVER OF LEGAL RIGHTS, AND ASSUMPTION OF RISK.

    In consideration of the opportunity to participate in events conducted by, and to use the facilities and premises owned/leased by, any instructor of the Eclipse Afrikan Cultural Arts Organization and its affiliates furtherance of martial arts, sparring, yoga, dance, aerobics, personal training, general exercise, weight lifting, and all other exercise-related activities (hereinafter collectively called “Martial Arts”), I hereby understand and agree to this Release of Liability, Waiver of Legal Rights and Assumption of Risk and to the terms hereof as follows:

     

    I acknowledge that Martial Arts is an action sport and recreational activity involving movement in three dimensions and that such activity is subject to mishap and even injury to or death of participants. I understand I may suffer broken bones, internal injuries, paralysis, or fatal injury, as well as the loss of or damage to personal property while participating in the sport of Martial Arts.

  • I hereby forever RELEASE AND DISCHARGE Eclipse Afrikan Cultural Arts and its affiliates, as well as all other participants of Martial Arts, volunteers, Eclipse Afrikan Cultural Arts officers, directors, elected officials, agents, employees, and owners of equipment and land and buildings used for Martial Arts activities (hereinafter collectively referred to as “Released Parties”), from any and all liability, claims, demands or causes of action that I or my representatives may hereafter have for injuries, loss of life, and all other funds of damages arising out of or relating to my participation in Martial Arts activities, including, but not limited to, losses CAUSED BY THE NEGLIGENCE OF THE RELEASED PARTIES.

    I hereby forever knowingly WAIVE all claims, demands, and causes of action against the Released Parties for injuries, loss of life, and all other forms of damages arising Out of or relating to my participation in Martial Arts activities, including, but not limited to, losses CAUSED BY THE NEGLIGENCE OF THE RELEASED PARTIES

    I understand and acknowledge that Martial Arts activities have inherent dangers that no amount of care, caution, instruction or expertise can eliminate and I EXPRESSLY AND VOLUNTARILY ASSUME ALL RISK OF DEATH OR PERSONAL INJURY OR OTHER FORMS OF DAMAGES SUSTAINED WHILE PARTICIPATING IN MARTIAL ARTS ACTIVITIES WHETHER OR NOT CAUSED BY THE NEGLIGENCE OF THE RELEASED PARTIES

    I further agree that I WILL NOT SUE OR OTHERWISE MAKE A CLAIM against the Released Parties for personal injury, death, damages or other losses sustained as a result of my participation in Martial Arts activities

    I also agree to INDEMNIFY AND HOLD THE RELEASED PARTIES HARMLESS from all claims, judgments and costs, including attorneys’ fees, incurred in connection with any action brought against them, jointly and severally, as a result of my participation in Martial Arts.

    I will take full responsibility for, and do not hold the Released Parties for any injury, property damage, or death that I may suffer or inflict upon others or their property as a result of my engaging in Martial Arts activities

  • Should be Empty: