Free Trial Class & Waiver Form

Parent/Guardian Information

Emergency Information

Informed Consent and Acknowledgment

I, the undersigned parent/guardian, hereby give my consent for my child’s participation in any and all activities organized by the K.E.E.P. After School Program & Kids Empowerment Enrichment Program during the selected programs. In consideration of my child’s participation, I acknowledge and accept the inherent risks associated with physical activities, including but not limited to Brazilian Jiu-Jitsu, self-defense training, fitness exercises, and sports-related activities.

I understand and agree that participation in these activities involves physical exertion and potential risks of injury, including but not limited to sprains, fractures, concussions, paralysis, or even death. I assume all risks and hazards incidental to the activities and hereby release, indemnify, and hold harmless K.E.E.P. After School Program & Kids Empowerment Enrichment Program, including all officers, instructors, employees, agents, volunteers, sponsors, affiliates, and representatives from any and all liability arising from my child’s participation, including travel to and from program locations.

In the event of an injury, I authorize K.E.E.P. After School Program & Kids Empowerment Enrichment Program staff to secure necessary medical treatment for my child. I further waive any claims against K.E.E.P. After School Program & Kids Empowerment Enrichment Program, its staff, partners, and facility owners arising from such medical care.

Medical Release and Authorization

As Parent and/or Guardian of the named participant, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the K.E.E.P. After School Program & Kids Empowerment Enrichment Program. and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Photography Release

Photography Release: In consideration of child(ren)’s participation at the Program, and without any further consideration from the Program, I hereby grant permission to the Program, staff and affiliates to utilize my child(ren)’s appearance, performance or voice in any and all manner and media throughout the world for the purpose of promotion, reporting or publication. The Program may use my child(ren)’s, likeness, voice and biographical material in connection with publication, promotion, exhibition and distribution of such material. I understand that no royalty, fee or any other compensation of any kind shall become payable to me by reason of such release and use of any photograph.

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.