Name *

First Name

Last Name

Pronouns

Select the choice that best describes you.

Female

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Date of Birth *

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YYYY

Address *

Provide your mailing address.

Address 1

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City

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Phone *

Provide your phone number.

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###

####

Emergency Contact Name *

Who should we contact in case of an emergency?

First Name

Last Name

Emergency Contact Phone Number *

Please provide the phone number for your emergency contact in case of an emergency.

Country

(###)

###

####

Emergency Contact Info *

What is your relationship to your emergency contact?

Spouse

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Release of Liability

In consideration for my attendance and participation at Prisby Martial Arts DBA Metrowest Kung Fu, I, the student or parent/guardian, acknowledge that the consultation of a physician is recommended prior to commencement of any exercise routine. I assume any and all risks of injury associated with or in any manner related to my use of or presence at any premises, use of any equipment, or participation in any sport, function, or activity in any way related to membership, including injury resulting from the negligence of any party. I also hereby state that the students named above are physically fit and mentally capable of taking the prescribed course of instruction and do so of their own free will for an agreed-upon fee. I understand that there is a no-refund policy on any monies I will pay to Prisby Martial Arts DBA Metrowest Kung Fu. This waiver applies regardless of whether I am participating in any class, practice, seminar, tournament, demonstration, or function at the time of the injury, or whether any injury occurs as a result of my presence upon the premises regardless of purpose or activity at the time of the incident leading to the injury. I understand that this waiver and release agreement is intended to be as broad as is allowed under applicable law and applies to any and all claims for damages, regardless of whether they are allegedly caused by the negligence of a league, a team, or their officers, directors, administrators, employees, or agents. I authorize Prisby Martial Arts DBA Metrowest Kung Fu to publish photographs taken of me at any time, and my name and likeness for use in print, online, and video-making materials, as well as other publications. I hereby release and hold harmless Prisby Martial Arts DBA Metrowest Kung Fu from any reasonable expectation of privacy or confidentiality associated with the images specified above. I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type associated with the taking or publication of these photographs or participation in company marketing materials or other publications. I acknowledge and agree that publication of said photos confers no right of ownership or royalties whatsoever. I hereby release Prisby Martial Arts DBA Metrowest Kung Fu, its contractors, its employees, and any third parties involved in the creation or publication of marketing materials, from liability for any claims by me or any third party in connection with my participation. I have read and agree to the above statements, as well as the Metrowest Kung Fu Student Code of Conduct.

Agree

Date

MM

DD

YYYY