RCC STREET SAFE SELF-DEFENCE WAIVER & RELEASE OF LIABILITY

RCC STREET SAFE SELF-DEFENCE WAIVER & RELEASE OF LIABILITY
Name Adult/Parent/Guardian*
Name of Child/Junior/Teen (If applicable)
ROSEBERRY COMMUNITY CONSORTIUM WAIVER & RELEASE OF LIABILITY
I(the undersigned) have been made fully aware of the nature and status of

participating in activities at Roseberry Community Consortium Street Safe Self- Defence as a whole and, having read the above waiver (freely and without coercion) fully accept the terms and conditions presented within. I understand and accept this
Member Details
Full Name*
Date of Birth*

DayMonthYear
Address*
Postcode*
Parent/Guardian
Name
Email address
example@example.com
Mobile
Landline
Emergency Contact #1*
Name & Number
Emergency Contact #2
Name & Number
Permission to receive First Aid, if required?*

YesNo
Permission to allow, photographs to be taken*

YesNo
Signature*

Clear
All participants who wish to participate in activities within and or organized by or through Roseberry Community Consortium must read, agree to, and complete this document prior to the commencement of any activity therein. Prior to training you are urged to seek out professional medical advice from either your General Practitioner (GP) or other qualified medical practitioner before taking part in any form of activity at Roseberry Community Consortium. Please indicate any medical considerations that we should be aware of that may affect you while participating at Roseberry Community Consortium.

Please note any Medical Considerations (or requirements) that you believe the Coaches of Roseberry Community Consortium should be aware of:

Please do not leave these blank
Please disclose any current medications you may be taking (including herbal medication)*
Please note any medical considerationsor requirements that you believe the Coaches of Roseberry Community Consortium should be aware of*
(We understand this medical information is private, and as such will not be shared, presented, or made public in any way other than to assist in the prevention of injury to the signatory (you or your child) below. If you would prefer not to disclose any medical information, or feel you would rather discuss the matter privately, then please approach a member of the management team or Roseberry Community Consortium coaches who will direct you to the correct person to contact.
PAR-Q (Physical Activity Readiness Questionnaire)
Common sense is your best guide when answering these questions. Please read the questions carefully and answer each one honestly.
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*

YesNo
2. Do you feel pain in your chest when you do physical activity?*

YesNo
3. In the past month have you ever had chest pain when you were not doing physical activity*

YesNo
4. Do you lose your balance because of dizziness or ever lose consciousness?*

YesNo
5. Do you have a bone or joint problem that could be made worse by a change in physical activity?*

YesNo
6. Is your doctor currently prescribing drugs for your blood pressure or heart conditions?*

YesNo
7. Have you had any surgical operations in the last 12 months?*

YesNo
8. Are you currently taking any medications (including herbal remedies)?*

YesNo
9. Do you know any reason why you should not do physical activity?*

YesNo
If you answered YES to one or more questions:

Please supply a letter from your GP or talk with your doctor by phone or in person BEFORE you start becoming much more physically active or before you have a fitness appraisal.

Tell your doctor about the PAR-Q and which questions you answered YES If you answered NO to all questions, you can be reasonably sure that you can: Start becoming physically more active-begin, slowly and build up gradually. This is the safest way to approach training. Take part in a fitness appraisal- this is an excellent way to determine your basic fitness so you can plan the best way to live actively.

PLEASE NOTE: If your health changes so that you answer YES to any of the above questions, it is paramount you inform the coaches or management team of Roseberry Community Consortium as soon as possible.
"I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction".

Note: This physical activity clearance is valid for a maximum of 12 months from the date and becomes invalid if your condition changes so that you would answer YES to any of the questions and inform the training professional.

"I understand that I have been advised to seek medical advice prior to undertaking physical exercise after completing PAR- Q however, I wish to continue to train at my own risk as I am fully aware of potential dangers and accept all responsibility and/or consequences that may occur as a result of
Name
Signature

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(Parent/Guardian consent and information is required to enable a person aged 17 years and under to participate in classes provided by Roseberry Community Consortium)
Name
Signature

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ROSEBERRY COMMUNITY CONSORTIUM WAIVER & RELEASE OF LIABILITY
DISCLAIMER: ROSEBERRY COMMUNITY CONSORTIUM (AND PARTICIPATING MEMBERS OF ROSEBERRY COMMUNITY CONSORTIUM) ARE NOT RESPONSIBLE FOR ANY INJURY (OR LOSS OF PROPERTY) TO ANY PERSON SUFFERED WHILE WATCHING OR PARTICIPATING IN ACTIVITIES AT ROSEBERRY COMMUNITY CONSORTIUM FOR ANY REASON WHATSOEVER, INCLUDING ORDINARY NEGLIGENCE ON THE PART OF THE MEMBERS OF ROSEBERRY COMMUNITY CONSORTIUM, INSTRUCTOR/COACH, MEMBER, VOLUNTEER, OR AGENT OF ROSEBERRY COMMUNITY CONSORTIUM OR ANY OTHER PARTICIPANT, VISITOR, OR PERSON PRESENT AT OR PARTICIPATING IN ACTIVITIES SUPPORTED BY ROSEBERRY COMMUNITY CONSORTIUM.
In consideration of my participation, I hereby release and covenant not to sue Roseberry Community Consortium, instructor/coach, member, volunteer, or agent of Roseberry Community Consortium or any other MMA participant, visitor, or person present at or participating in activities supported by Roseberry Community Consortium, from any or all present and future claims resulting from ordinary negligence on the part of the Roseberry Community Consortium or others listed for property damage, personal injury, or wrongful death, arising as a result of my engaging in or receiving instruction in Roseberry Community Consortium sponsored activities or any activities incidental thereto, wherever, whenever, or however the same may occur. I hereby voluntarily wave any and all claims resulting from ordinary negligence, both present and future, that may be made by me, my family, estate, heirs, or assigns. Further, I am aware of the following risks, and NUMEROUS OTHER INHERENT RISKS in observing or participating in activities and Brazilian Jiu-Jitsu or Mixed Martial Arts sponsored by Roseberry Community Consortium. These risks include, but are not limited to, death, or serious injury resulting from: physical contact while observing or participating in activities supported by Roseberry Community Consortium; including, but not exclusive to collision (with other persons or objects), being struck on the body or head, being thrown or dropped, suffocation resulting from choking or strangulation, dropped equipment, dehydration, exertion, while participating in activities at Roseberry Community Consortium, ORDINARY NEGLIGENCE of the coaches, and members or volunteer assistants of Roseberry Community Consortium, those persons at the Roseberry Community Consortium who, lacking adequate training, seek to assist with medical or other help either before or after injuries have occurred.
Iam voluntarily participating in this activity with knowledge of the danger involved and

hereby agree to accept any and all inherent risks of property and personal damage or

I further agree to indemnify and hold harmless Roseberry Community Consortium and any other listed for any and all claims arising as a result of my engaging in or receiving instruction in activities sponsored by Roseberry Community Consortium, or any activities incidental thereto, wherever, whenever, or however the same may occur. I understand that this waiver is intended for to be as broad and inclusive as permitted by the laws of the England and Wales, and agree that if any portion is held invalid, the remainder of the waiver will continue in full legal force and effect. I further agree that the venue for any legal proceedings shall be in England. I affirm that I am of legal age and freely sign this agreement. I have read this form and fully understand that by signing this form, I am giving up all legal rights and/or remedies which may be available to me for the ordinary negligence of the Roseberry Community Consortium or any of the parties listed above. By accepting this document, I acknowledge that I have voluntarily chosen to participate in physical exercise. In accepting this document, I acknowledge being informed of the strenuous nature of the activity and the potential for unusual, but possible, physiological results including but not limited to abnormal blood pressure, fainting, heart attack or even death.

Ialso understand that I may stop any training session at any time. By accepting this

document, I assume all risk for my health and wellbeing and any resultant injury or mishap that may affect my wellbeing or health in any way and hold harmless of any responsibility, the instructor, facility or persons involved with the program and testing procedures.

Sign below and over the page if you agree to these conditions:
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RCC STREET SAFE SELF-DEFENCE WAIVER & RELEASE OF LIABILITY

ROSEBERRY COMMUNITY CONSORTIUM WAIVER & RELEASE OF LIABILITY

Member Details

Parent/Guardian

PAR-Q (Physical Activity Readiness Questionnaire)