Youth Liability Waiver and Assumption of Risk Agreement for Black Lotus Training Center, LLC (DBA Black Lotus Gym)
Minor's Full Name
*
First Name
Last Name
Minors DOB
*
-
Month
-
Day
Year
Date
Siblings Full Name
First Name
Last Name
Sibings DOB
-
Month
-
Day
Year
Date
Contact Email Address (Parent/Guardian)
*
example@example.com
Contact Phone Number (Parent/Guardian)
*
-
Area Code
Phone Number
(Parent/Guardian) Full Name
*
First Name
Last Name
Relationship to the Minor
*
Participants Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the minor have any medical conditions or injuries that may affect participation? (Yes/No)
*
If "Yes," provide details.
How did you hear about us?
Drive by
Social Media (Instagram)
Social Media (Facebook)
Direct Search
Referred by a student or coach (please add name in "other)
Other
Type a question
*
Drive By
Direct Search
Social Media (Instagram)
Social Media (Facebook)
Referred by a student or coach (please add name in "other)
Flier
Other
Consent for Participation in Adult Classes
By signing below:I consent to my teen participating alongside adults in partner-based classes at Black Lotus Training Center.I understand that while Black Lotus Training Center strives to pair minors with other minors whenever possible, there may be instances where my child will train with adult partners due to class composition.I acknowledge that martial arts training involves physical contact and partnering exercises. Black Lotus Training Center will take reasonable measures to ensure safety but cannot guarantee age-specific pairings at all times.I voluntarily consent to this arrangement and assume all risks associated with my child's participation.
Do you consent to your teen participating in adult classes?
Yes
No
Initial here to confirm that you understand and agree:
Assumption of Risk and Release of Liability
I understand that participation in martial arts, yoga, fitness activities, and related programs involves inherent risks, including but not limited to physical injury, emotional distress, property damage, or other harm. These risks may arise from the nature of the activities, equipment used, or actions of other participants.I voluntarily assume all risks associated with my child's participation in these activities at Black Lotus Training Center, LLC.I release, indemnify, and discharge Black Lotus Training Center, LLC; its owners, instructors, employees, agents; and all students from any and all liabilities, claims, demands, actions, or causes of action arising out of or related to my child's participation in classes, programs, or use of facilities and equipment. This release includes liability for negligence to the fullest extent permitted by Florida law.I certify that my child possesses a sufficient degree of physical fitness to safely participate in these activities and has no medical condition that would prevent participation or increase the risk of injury.
Protective Equipment Responsibility
I acknowledge that Black Lotus Training Center strongly recommends the use of protective equipment (e.g., gloves, shin guards, mouthguards) during training sessions.By signing below:I understand it is my responsibility to ensure my child wears appropriate protective gear during class as directed by instructors.I acknowledge that failure to follow these recommendations may increase the risk of injury and release Black Lotus Training Center from liability for injuries resulting from lack of protective equipment.
Emergency Medical Authorization
In the event of an emergency where I cannot be reached:I authorize Black Lotus Training Center staff or instructors to seek medical treatment for my child as deemed necessary by licensed medical personnel.I agree to bear all costs associated with such treatment.
Photo/Media Release
By signing this waiver, I acknowledge and agree to the following:I grant Black Lotus Training Center, LLC, its affiliates, and representatives permission to use photographs, videos, or other digital media featuring myself or my minor child for promotional purposes. This includes but is not limited to social media, websites, advertisements, and printed materials.I understand that all photos and videos will become the property of Black Lotus Training Center, LLC and will not be returned.I irrevocably authorize Black Lotus Training Center, LLC to edit, alter, copy, exhibit, publish, or distribute these photos or videos for any lawful purpose without payment or other consideration.I waive any right to inspect or approve the finished product in which my likeness or my child’s likeness appears. Additionally, I waive any right to royalties or other compensation arising from the use of these materials.If I do not consent to this media release, I understand it is my responsibility to contact Black Lotus Training Center in writing at blacklotusgym@gmail.com prior to participation in any classes or events.By signing below, I release and hold harmless Black Lotus Training Center, LLC from all claims, demands, and causes of action arising out of the use of these images or videos.
Acknowledgment and Agreement
I have read and fully understand this waiver and release of liability form. By signing below:I acknowledge that I am voluntarily agreeing to these terms on behalf of my minor child.I certify that I am the parent/legal guardian authorized to sign this waiver on behalf of my child.I agree that this waiver is binding upon me, my heirs, executors, administrators, successors, and assigns.
Signature
Date
*
-
Month
-
Day
Year
Date Picker Icon
Save
Submit
Submit
Should be Empty: