Empower & Protect – Self Defense Essentials

I   First Name*   Last Name*, hereby acknowledge, understand and assume all risks relating to participating in a Self-Defense class offered by the COUNTY OF UNION and/or any other individuals, employees or volunteers involved in the instruction (collectively the “Instructor”) and understand and agree that my participation may involve injury of some type to and involve risks to my person, or a fellow participant, including bodily injury, partial or total disability, paralysis and death, and damages which may arise therefrom and that I have full knowledge of said risks including those which may be caused by my negligence and/or others, are included within the waiver and release described in this agreement.

I,   First Name*   Last Name*, acknowledge and understand that such injury can include direct physical and possible crippling injury to my body them and the possibility of emotional injury experienced as a result of witnessing or actually accidentally inflicting injury to another. The severity of such injury can range from a minor injury to complete paralysis, or even death. Such injury can impair my general physical and mental health and hinder my future ability to earn a living and generally to enjoy life. Risks that may be encountered may include cardiac or respiratory distress; bone or joint injuries; back or muscle injury; slipping, tripping or falling; lifting, twisting, straining, spraining or breaking an appendage; or other trauma or injury. This list is non-exhaustive and is provided by way of illustration of risks or injuries that may be incurred.

I,   First Name*   Last Name*, acknowledge, understand and agree that the Instructor will make no evaluation or recommendation whether I am physically fit for any physical activity. If you have any physical condition that may impair your ability to engage in the activities, it is your responsibility to obtain a physician's statement describing any limitation to participate in this Self-Defense class. It is always advisable to consult a physician prior to undertaking any physical exercise program.

I,   First Name*   Last Name*, acknowledge and understand the Self-Defense class has been designed to provide me with techniques to survive and escape a physical assault. However, I understand that the Instructor cannot guarantee my safety through the use, or misuse, of the techniques taught in the class.

FOR AND IN CONSIDERATION OF ME BEING ALLOWED TO PARTICIPATE IN SELF-DEFENSE CLASS OFFERED BY THE INSTRUCTOR, I, MY HEIRS, EXECUTORS, ADMINISTRATORS AND ASSIGNS HEREBY WAIVE, RELEASE, HOLD HARMLESS AND INDEMNIFY INSTRUCTOR, ITS BOARD OF COUNTY COMMISSIONERS, EMPLOYEES, AGENTS, VOLUNTEERS AND CONTRACTORS AND THEIR HEIRS, SUCCESSORS, ASSIGNS, ATTORNEYS, AGENTS, ACCOUNTANTS, EXECUTORS AND ADMINISTRATORS FROM ANY AND ALL CLAIMS FOR LIABILITY AND CAUSE(S) OF ACTION, INCLUDING FOR PERSONAL OR BODILY INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH OR ANY OTHER DAMAGE OR INJURY OCCURRING TO, ARISING OUT OF MY PARTICIPATION IN THE SELF-DEFENSE CLASS OFFERED BY INSTRUCTOR, WHENEVER OR HOWEVER THEY OCCUR INCLUDING ANY AND ALL CLAIMS, CAUSES OF ACTION, ACTIONS, LIABILITIES, DEBTS, DEMANDS, DAMAGES, COSTS, SUITS, ACCOUNTS, COVENANTS, CONTRACTS, AGREEMENTS, COUNTERCLAIMS, CLAIMS FOR ATTORNEY’S FEES AND EXPENSES WHATSOEVER OF EVERY NAME AND NATURE, BOTH IN LAW AND IN EQUITY, KNOWN AND UNKNOWN, WHICH AGAINST THE SAID INSTRUCTOR, I MAY HAVE NOW, MAY HAVE OR EVER WILL HAVE.

I HEREBY ACKNOWLEDGE THAT I HAVE READ AND DO UNDERSTAND THE ABOVE INFORMATION AND WARNING OF RISKS AND THAT I VOLUNTARILY WAIVE ANY AND ALL CLAIMS AGAINST THE INSTRUCTOR AND CHOOSE TO PARTICIPATE AND THAT I INTEND TO LEARN AND FOLLOW ALL SAFETY PROCEDURES AND RULES.

PARTICIPANT                                                

                                          

Signature*                               

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First Name*   Last Name*                                 

Full Name           

 

Date*   
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