Name: First: {first_name} ___________ Last: {name} ______________
D.O. B: {dob} Address: {address} _____________________ ___________
Phone (Home/Cell): {phone} ____________ Phone #2 (Other):{phone} _______________
Emergency Contact Number: {contact_phone} ___________Contact Name: {contact_name} _
Email Address: {email} _
How Did You Hear About Us? Google Other: ___
Do you have any medical concerns?
NO submit a doctor’s note specifically stating you are fit to participate in a high intensity fitness workout)
Release and Waiver of Liability and Indemnity Agreement
(Read Carefully Before Signing)
In consideration of being permitted to participate in any way in the Martial Arts Program indicated below and/or being permitted to enter for any purpose any restricted area (here in defined as any area where in admittance to the general public is prohibited), the parent(s) and/or legal guardian(s) of the minor participant named below agree:
1. The parent(s) and/or legal guardian(s) will instruct the minor participant that prior to participating in the below martial arts activity or event, he or she should inspect the facilities and equipment to be used, and if he or she believes anything is unsafe, the participant should immediately advise the officials of such condition and refuse to participate. I understand and
agree that, if at any time, I feel anything to be UNSAFE ; I will immediately take all precautions to avoid the unsafe area and REFUSE TO PARTICIPATE further.
2. I/We fully understand and acknowledge that:
a. There are risks and dangers associated with participation in martial arts events and activities which could result in bodily injury, partial and/or total disability, paralysis and death.
b. The social and economic losses and/or damages, which could result from these risks and dangers described above, could be severe.
c. These risks and dangers may be caused by the action, inaction or negligence of the participant or the action, inaction or negligence of others, including, but not limited to, the Releasees named below.
d. There may be other risks not known to us or are not reasonably foreseeable at this time.
3. I/WE accept and assume such risks and responsibility for the losses and/or damages following such injury, disability, paralysis or death, however caused and whether caused in whole or in part by the negligence of the Releases named below.
4. I/We HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the martial arts facility used by the participant, including it owners, managers, promoters, lessees of premises used to conduct the martial arts event or program, premises and event inspectors, underwriters, consultants and others who give recommendations, directions or instructions to engage in risk evaluation or loss control activities regarding the martial arts facility or events held at such facility and each of them, their directors, officers, agents, employees, all for the purpose herein referred to as “Release” … From all liability to the undersigned, my/our personal representatives, assigns, executors, heirs and next to kin for any and all claims, demands, losses or damages and any claims or demands therefore on account of any injury, including but not limited to the death of the participant or damage to property, arising out of or relating to the events(s) caused alleged to be caused in whole or in part by the negligence of the release or otherwise.
5. I/We HEREBY acknowledge that THE ACTIVITIES OF THE EVENT(S) ARE VERY DANGEROUS and involve the risk of serious injury and/or death and/or property damage. Each of THE UNDERSIGNED also expressly acknowledges that INJURIES RECEIVED MAY BE COMPOUNDED OR INCREASED BY NEGLIGENT RESCUE OPERATIONS OR PROCEDURES OF THE RELEASEES.
6. EACH OF THE UNDERSIGNED further expressly agrees that the foregoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as is permitted by the law of the Province or State in which the event is conducted and that if any portion is held invalid, it is agreed that the balance shall, notwithstanding continue in full legal force and effect.
7. On behalf of the participant and individually, the undersigned partners(s) and/or legal guardian(s) for the minor participant executes this Waiver and Release. If, despite the release, the participant makes a claim against any of the Releases, the parents(s) and/or legal guardian(s) will reimburse the Release for any money which they have paid to the participant, or on his behalf, and hold them harmless.
8. The undersigned permits Black Feather Martial Arts Inc to use, reproduce, and/or publish photographs and/or video that may pertain to him/her, including image, likeness and/or voice without compensation. The undersigned understands that this material may be used in various publications, public affairs releases, recruitment materials, broadcast public service advertising (PSAs) or for other related endeavors. This material may also appear on Black Feather Martial Arts Inc social media or Internet web page.
9. Black Feather Martial Arts Inc is NOT responsible or liable for any lost or stolen property of any member or guest of our facility.
I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.
Martial Arts School: Black Feather Martial Arts
Black Feather Martial Arts Membership Agreement:
Last Name: {name} ______________ First Name:{first_name} ______________________
This document is an application for martial arts and fitness related training services and will form an agreement between the member and Black Feather Martial Arts Inc.
I, {first_name} _____________________, will make no representation or warranties, written or oral, express or implied, other than those is this agreement.
Refunds, Transfers and Pay-In-Full cancellation by client: This Black Feather Martial Arts Inc Pay in Full Membership agreement is non-refundable and non- transferable by the client and may not be canceled by the client. Black Feather Martial Arts Inc. has the right to revoke the members training contract in writing to the client if:
a. Any health information given by the member on the previous pages is false or changes.
b. The client breaches any of the rules of this agreement or the facility.
The only exception of our refund policy will be during the 10 days later to the date the written copy of the agreement was signed according to your rights under the Consumer Protection Act 2002.
Billing agreement
I (we) authorize Black Feather Martial Arts Inc, to process a debit, in paper, electronic or other form in the amount of $________ /monthly on my (our) account beginning____/_____/_____. I (we) have read and understood all the provisions contained in the terms and conditions of the pre-authorized payment authorization and that I (we) have received a copy. Payment will continue to be debited until payer Cancels or Freezes (a maximum of 3 months) on a Black Feather Martial Arts Inc. Amendment form in person, (email and phone calls are not accepted) provided there are no outstanding payments.
Interruption of service, and Cancellation or Hold of Account(s)
Membership can be frozen for a Maximum of 3 months.
Holds or Cancellations of services requires 30-day notice in person on a Membership Amendment Form. Payers can not cancel or freeze membership with any outstanding payments. Use of service is at the discretion of the member. Unused services do not constitute grounds for credits or refunds.
Prepaid memberships cannot be refunded. Any holds do not affect the payment schedule and will extend term for the same duration.
In the event of pregnancy, memberships must be frozen for safety reasons. Appropriate arrangements will be made by Black Feather Martial Arts Inc.
All students under the age of 18 must be accompanied by an adult to all classes and have a Parental Consent Form completed by a legal guardian or parent.
If by any reason of death or permanent disability, the participant is unable to complete the program, he/she shall be relieved of the obligation of making payment other than for services performed prior to death or onset of disability.
Delinquent Payments
Student/Participant Signature
Black Feather Martial Arts