Sign UpOnline Fill Out the Waiver & Release of Liability Below Waiver & Release of Liability Liability Waiver Date MM slash DD slash YYYY Name First Last DOB MM slash DD slash YYYY GenderAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone (Include Area Code)Your Email(Required) Emergency Contact First Last Cell PhoneOccupationPLEASE FILL OUT FOR MINORMother's NameCell PhoneOccupationFather's NamePhoneOccupationPayee's Name (If different than parent or student)Cell PhoneHow did you find out about Big Sky Martial Arts? Internet Social Media Drive By Radio Referral What interests you the most about Martial Arts? Self Defense Sport Competition Discipline Exercise Have you suffered or do you have any past injury or physical disabilities? Yes No If yes, please explain:Do You Have Heart Disease Diabetes Asthma High Blood Pressure Orthopedic Concerns What prescription medications do you take that might affect physical activity?Is your Physician aware you are starting an exercise program? Yes No I, undersigned, acknowledge that I have voluntarily chosen to participate in Martial Arts from Big Sky Martial Arts Inc., and have full knowledge of the risks that this activity presents, including travel to, participation in, and returning from activity or event and utilization of any of the equipment including the matted flooring including imperfections that may be present because it is a matted floor. I understand and agree that by being permitted to participate in Martial Arts activities I agree to assume any and all risks of injury or death. I further understand and agree to assume responsibility for all risk of theft, loss or damage of personal property which occurs at any time arising out of participation in Martial Arts activities. I understand and agree that as a condition of participation in Martial Arts activities, I further agree to release from liability and the indemnify Big Sky Martial Arts Inc., their officers, directors, agents employees, assigns, successors or lessors for any damage, injury, death to myself or to any person of property, in any way connected with my participation in martial Arts activities. I understand and agree that I have carefully read this agreement and fully understand all of its terms and conditions. I understand that this is a release of liability which could legally prevent me from filing a suit or making any other legal claim for damages in the event of my death or injury to me. With this knowledge, I am entering into this agreement freely and voluntarily. I agree that it is binding upon me, my assigns, and legal representatives. I understand and agree that if I am signing this waiver and release on behalf of my minor child, that I will be giving up the same rights for minor as I would be giving up if I signed this document on my own behalf. I understand and that I have read this waiver and release, have provided all necessary information, and have signed in the appropriate places. I also give permission to use, reprint, and reproduce any photograph or video taken of me and any written material supplied by me in the form of evaluations, during Martial Arts activities.Consent(Required) I agree to the terms and conditions explained above* By electronically signing this document you agree that your electronic signature is the binding equivalent to your handwritten signature, and you are also confirming that you are the individual named in the electronic signature and are authorized to sign this document.Participant Signature(Required)Parent or Guardian Signature:Must be signed by a parent or legal guardian if the participant is under the age of 18 years. Δ
