Bully Defense XplosiveFit Martial Arts Athlete

XplosiveFit Martial Arts Athlete Information -- Bully Defense
Child's Information
Child's Full Name*

First NameLast Name
Age of Child*
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Legal Guardian Information
Full Name*

First NameLast Name
Relationship to Child*
If Relationship is Other - please explain
Phone Number*

Area CodePhone Number
Email*
Emergency contact*

First NameLast Name
Phone number*

Area CodePhone Number
Social Media Contact Information
Can we connect with you on Facebook, Twitter, LinkedIn and Instagram?*

YesNo
Facebook Name
Twitter Name
LinkedIn Name
Instagram Name
Is it okay if we send you our eNewsletters? You can unsubscribe at anytime.*

YesNo
How did you hear about XplosiveFit and/or who do we thank for referring you to us?*
We like to take photos and videos during Lil Warriors. We do not tag children, but we like to tag the parent(s). . Are you okay with us using these photos/videos on our website, Facebook, Twitter, Instagram, YouTube, etc.?*

Yes, it is okayNo, I prefer that you not take photos/videos of my child
Is there something specific you would like us to work on with your child. Let us know here:
Name of school your child attends or indicate if child is homeschooled:*
Name of your child's teacher:*
Child's current grade (Pre-School, Kinder, 1st, etc., or not in school yet)*
Health questionnaire
Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

	Yes	No
Has your doctor ever said that your child has a heart condition and that you should only do physical activity recommended by a doctor?
Has your child ever felt pain in their chest when doing physical activity?
In the past month, has your child had chest pain when not doing physical activity?
Has your child lost their balance because of dizziness or ever experienced a a loss of consciousness?
Does your child have any bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in physical activity?
Is your doctor currently prescribing drugs to your child for blood pressure or heart condition?
Do you know of any other reason why your child should not do physical activity?

Please enter any additional information that you would like us to know about your child:
I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction
Initials*

Clear
Liability Waiver
I am aware of the risks in observing or participating in the activities offered and sponsored by XplosiveFit and I understand that all sports or fitness that I will execute and participate in are entirely at my own risk and perils. I assume complete responsibility and liability for those risks and for the injuries that may occur as a result of these risks, even if injuries occur in a manner that is not foreseeable at the time I sign this agreement. I realize that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me, damage to my property, or damage arising out of my death.

It is further expressly agreed that all strength training, cardiovascular exercise, or any other exercise shall be undertaken by me at my sole risk and that Rodrigo Busby and his agents or employees shall not be liable to me for claims, demands, injuries, damages, actions or causes of actions, from all acts of active or passive negligence on the part of Rodrigo Busby and his agents or employees. I further expressly agree that I will not use equipment improperly. If I have any questions whatsoever, concerning exercise and use of equipment, I agree that I will request instruction from Rodrigo Busby and or his agents or employees.
Initials*

Clear
DO NOT SIGN THIS AGREEMENT UNLESS YOU UNDERSTAND THE TERMS COMPLETELY. IF YOU DO NOT UNDERSTAND, YOU SHOULD SEEK LEGAL COUNSEL.
Client Signature
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

XplosiveFit Martial Arts Athlete Information -- Bully Defense

Child's Information

Parent/Legal Guardian Information

Social Media Contact Information

Health questionnaire

Liability Waiver

DO NOT SIGN THIS AGREEMENT UNLESS YOU UNDERSTAND THE TERMS COMPLETELY. IF YOU DO NOT UNDERSTAND, YOU SHOULD SEEK LEGAL COUNSEL.

Client Signature