Capoeira Amizade Flagstaff Registration and Waiver Form

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Name *

Email *

Phone number

Please describe any past capoeira or related experience, if any *

What do you expect to gain through a regular capoeira practice? *

Please describe any health- related conditions that you have (or have had in the past that could affect your capoeira practice- including but not limited to: bone, muscle, ligament, tendon injury, heart, lung, blood pressure, back or neck pain or injury, epileptic, diabetic or thyroid conditions, pregnancy and any medications that you are currently taking (including their side effects). If none, please enter N/A. *

Emergency Contact Full Name and Relationship *

Emergency Contact Phone *

Waiver - Acknowledgment of Program Participant Responsibility, Express Assumption of Risk, and Release of Liability

I hereby agree to the following:
1. That I am in good health and suffer no physical impairment which would limit my participation in the Capoeira Angola and Capoeira Amizade Flagstaff classes. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in activities with Capoeira Amizade Flagstaff classes.
2. That I am aware that participation in any activity or physical activity may result in accident or injury, and I assume the risk connected with the participation in an activity or exercise. The physical activity I am participating in with Capoeira Amizade Flagstaff requires physical exertion that may be strenuous, may include physical contact, and may cause physical injury, and I am fully aware of the risks and hazards involved.
3. In order to be permitted to participate in classes, programs or workshops, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in activities with Capoeira Amizade Flagstaff.
4. That if I am a woman and I am or become pregnant, I will let Capoeira Amizade Flagstaff know immediately.
5. That Capoeira Amizade Flagstaff, its officers, employees, agents, directors, volunteers, independent contractors shall not be liable for any claim, demand or cause of action of any kind whatsoever for, or on the account of, death, personal injury, property damage or loss of any kind resulting from or related to my use of the facility or participation in any sport, exercise or activity within or without the center’s premises, and I agree to hold Capoeira Amizade Flagstaff harmless from the same, except as limited by law.
6. That I knowingly, voluntarily and expressly waive any claim I may have against Capoeira Amizade Flagstaff for injury or damages that I may sustain as a result of participation in their programs or those conducted by independent contractors on the premises, except as limited by law.
7. I, my heirs or legal representatives forever release, waive, discharge and covenant not to sue Capoeira Amizade Flagstaff for any injury or death caused by my participation in any activities at or with Capoeira Amizade Flagstaff, except as limited by law.

Participant Consent *

By checking this box and entering my initials below, I am effectively providing my signature, certifying that all the information on this form is true and correct.

Todays Date *

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Participant Initials *

Todays Date *

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