Lei Shan Dao Waiver and Consent Form
Please provide your details and consent to participate in martial arts activities.
Participant Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Health Conditions Screening
*
Rows
Yes
No
Heart Disease
Asthma
Diabetes
High Blood Pressure
Epilepsy
Joint or Bone Injuries
Back Problems
Respiratory Issues
Recent Surgeries
Dizziness or Fainting
Allergies
Other
If you answered Yes to any health conditions, please provide details here.
Participant Signature
*
Submit Waiver
Submit Waiver
Should be Empty: