AU Waiver

Name*

First NameLast Name

Kid's Name

First NameLast Name

Date of Birth*

MonthDayYear

Contact Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Emergency Contact*

First NameLast Name

Emergency Contact's Number*

Area CodePhone Number

Health

(Good, Fair, Poor, List of there's problems)

How did you hear about us?

Referred By:

As a guest, I hereby agree to release and to hold harmless from any claims or causes of action that I (my child) may have, ARTS UNITED CAPOEIRA, all respective staff members, administrators, students, guests, and all others affiliated with ARTS UNITED CAPOEIRA from any responsibility for injury, damages or loss that I (my child) may sustain as a result or my (child’s) training, including but not limited to my (child’s) participation in class activities and events (e.g. tournaments, demonstrations, training clinics, training camps, etc.) or the use of equipment provided to or sold to me (my child) in connection with my (child’s) training. Guests are welcome to enjoy our academy in accordance with all rules and guidelines. As a guest, I promise that I am in good physical condition and able to use the equipment, facility and services provided by Arts United CAPOEIRA. The academy shall NOT be liable for ANY injury person or others, or loss of property while one said premises. Guests are welcome to enjoy our academy in accordance with all rules and guidelines.

BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ ALL OF THE TERMS, CONDITIONS AND STATEMENTS OF THIS AGREEMENT AND UNDERSTAND, ACCEPT AND AGREE TO ALL MADE HEREIN.

Signature*

Signature Date

MonthDayYear

Class Waiver