Martial Arts Waiver Form

Martial Arts Waiver Form

Please read and sign the waiver form before participating in martial arts classes.
1 - APPLICANT'S DETAILS
Full Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Name of Employer
2 - PARENT / GUARDIAN CONTACT DETAILS

If Applicant is under 18
Parent/Guardian 1 Full Name

First NameLast Name
Parent/Guardian 1 Email
example@example.com
Parent/Guardian 1 Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Parent/Guardian 2 Full Name (if participant is a minor)

First NameLast Name
Parent/Guardian 2 Email
example@example.com
Parent/Guardian 2 Phone Number
Please enter a valid phone number.Format: 0000 000 000.
3 - MARKETING / REFERRAL INFORMATION
How did you hear about us?
Other? Please list
Were you referred by someone? If so, by who?
4 - HEALTH DECLARATION
Are you prescribed drugs which may impair reaction time or judgment?
If YES, what drugs?
Have you suffered any incapacity requiring medical attention in the past 12 months?
If YES, give details
Do you have any physical impairments, injuries or medical conditions that currently affect you?
If YES, give details
Are you aware of any health problem that you have that, in the interests of your safety Hills Academy of Martial Arts should be advised of?
If YES, give details?
5 - MARTIAL ARTS HISTORY
Have you studied / participated in martial arts?
If YES, give details including - style, years studied, grade achieved, name of instructor/academy
6 - EXCLUSION OF APPLICANT
Have you ever been excluded from participation in martial arts or sport in the past by a medical practitioner or any other person or entity or instructor / coach, or a martial arts club?
If YES, give details
7 - MARTIAL ARTS GOALS
Please check all boxes that are most beneficial to you /your child
What are your top 1, 2 or 3 Goals / Benefits that you would like (you/your child) to achieve?
On a Scale of 1-10, how important is it that you achieve this goal?

1

2

3

4

5

6

7

8

9

10

1 is Not Important, 10 is Very Important
8 - WAIVER AND INDEMNITY
In all other cases and except where inconsistent with the above, the Applicant for him/herself, his/her executors, administrators, dependents and other personal representatives, hereby absolves and indemnifies the providers and all their servants, agents, employees and other students or persons under the providers control (the "indemnified") from all liability arising for injury or damage (including but not limited to the Applicants' person, whether fatal or otherwise) however caused including by the negligence of the indemnified, arising out of or participating in Martial Arts or in connection with Martial Arts or in any way caused by, or arising out of, any activity carried on by the indemnified.

I, the Applicant, have been advised and understand that the practice of martial arts is potentially dangerous.

I, the Applicant, agree to occupy and use the premises of Hills Academy of Martial Arts at risk to myself and release to full extent permitted by law Benjamin Copeman, Hills Academy of Martial Arts, and its agents, servants, contractors and employees from all claims and demands of every kind in of or resulting from any accident or injury or death to myself while undertaking training in martial arts with Hills Academy of Martial Arts.

The Applicant warrants acknowledges that all medical attention or treatment afforded to me by Hills Academy of Martial Arts and its representatives, volunteers and all other related members will be of first aid only, and hereby release Hills Academy of Martial Arts and its representatives, volunteers and all other related members from any liability for administering such aid.
9 - MARTIAL ARTS DONE AT APPLICANT'S OWN RISK
Any person training Martial Arts, or in activities connected with Martial Arts or participating in any activity carried on by Hills Academy of Martial Arts are only allowed to do so on the distinct understanding that they do so entirely at their own risk.
10 - DECLARATION OF UNDERSTANDING
Martial Arts Is Dangerous

I have read and understood the terms of the Martial Arts Contract or if I did not understand the terms of the Contract, I requested an independent person to explain them to me.
Applicant Signature
11 - PARENT/GUARDIAN'S CONSENT (for all person's under 18)
I hereby certify and decree that all the information contained in the declarations above is true and accurate.
Name of Parent/Guardian
Relationship to Applicant
Parent/Guardian Signature
Hills Academy of Martial Arts

ABN: 12 828 557 767

34/7 Carrington Rd, Castle Hill NSW 2154

www.hillsmartialarts.com.au
Should be Empty:

Martial Arts Waiver Form

1 - APPLICANT'S DETAILS

2 - PARENT / GUARDIAN CONTACT DETAILS

3 - MARKETING / REFERRAL INFORMATION

4 - HEALTH DECLARATION

5 - MARTIAL ARTS HISTORY

6 - EXCLUSION OF APPLICANT

7 - MARTIAL ARTS GOALS

8 - WAIVER AND INDEMNITY

9 - MARTIAL ARTS DONE AT APPLICANT'S OWN RISK

10 - DECLARATION OF UNDERSTANDING

11 - PARENT/GUARDIAN'S CONSENT (for all person's under 18)