ArteLuta Capoeira: Participant Acknowledgement & Releases
Email address *
Your contact phone number *
Full Name of Participant(s) - If you are filling this form out for multiple participants, please list all first and last names, separated by a comma. *
Participant(s) Date of Birth - If you are filling this form out for multiple participants, please list all DOBs, separated by a comma. *
Parent or Guardian's Name (if participant is under 18):
Parent or Guardian's Cell Phone Number:
Name of Emergency Contact: *
Emergency Contact Cell Phone Number: *
List any injuries, physical or health problems you/your child(ren) have that we should be aware of: *
Have you/your child(ren) studied martial arts before? *
If yes, list what type and for how long.
What are your reasons for wanting to learn capoeira? Check all that apply. *
What would like us to know about you/your child(ren)? *
I hereby acknowledge that I/ my child(ren) are voluntarily participating in Capoeira instruction and training at ArteLuta Capoeira Academy. I hereby waive any right, claim or cause of action against ArteLuta Capoeira, Luiz O. Pereira (Varal) or any instructor of ArteLuta Capoeira, as a result of participating or engaging in any physical contact or other supervised activity which is part of my capoeira training.

I hereby assume responsibility for any injury which may result from my voluntary participation and hereby hold harmless ArteLuta Capoeira, and its instructors, should injury or loss occur while I, my child(ren) participate(s) in said voluntary activity. I also understand that this acknowledgement and release covers claims and liabilities caused by and acts or failures to act of ArteLuta Capoeira, including but not limited to, mistake, negligence, or failure by ArteLuta Capoeira, its employees and/or representatives.

As lawful consideration for being permitted by ArteLuta Capoeira to participate in these activities and use their facilities, I hereby agree that I, my heirs, distributes, guardians, legal representative and assigns will not make claim against, sue, attack the property of, or prosecute ArteLuta Capoeira, its employees, agents, representatives, or Luiz O. Pereira personally, for any injury or damage resulting from participating in such activities.
Click Yes to indicate that you have read, understand and agree to our Participant Acknowledgement and Release of Liability. *
Photo/Media Release
I understand that ArteLuta Capoeira may wish to use photographs of me/my child for published promotional medium or otherwise. I hereby consent and give ArteLuta Capoeira permission to take photographs and/or digital video images of me/my child and to use and publish such photographs, together with any caption or descriptive material, for advertising, publicity, or any other purposes in ArteLuta Capoeira’s promotional medium, or in any other publication or manner that ArteLuta Capoeira may authorize. I waive the right to inspect or approve any photographs or digital video images before they are published and any use to which they may be put. I release ArteLuta Capoeira and its employees of and from all debts, claims and liability of any kind arising out of or in connection with the taking and use of photographs, the use of my name and the use of any caption or descriptive material therewith.
Click Yes to indicate that you have read, understand and agree to our photo/media release. *
Assumption of Risk and Waiver of Liability Relating to Coronavirus (COVID-19)
I agree that I am personally responsible for my/my child(ren)'s safety and actions while participating in classes at ArteLuta Capoeira. I agree to comply with all ArteLuta Capoeira's guidelines and precautions. Because ArteLuta Capoeira is open for use by other individuals, I recognize that I am/my child(ren) is at higher risk of contracting COVID-19. With full awareness and appreciation of the risks involved, I, for myself, my child(ren) and on behalf of my family, spouse, estate, heirs, executors, administrators, assigns, and personal representatives, hereby forever release, waive, discharge, and covenant not to sue ArteLuta Capoeira, its board members, officers, agents, servants, independent contractors, affiliates, employees, successors, and assigns (collectively the “Released Parties”) from any and all liability, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, or injury, including death, that may be sustained by me/my child(ren) related to COVID-19 whether caused by the negligence of the Released Parties, any third-party using ArteLuta Capoeira's facilities, or otherwise, while participating in any activity while in, on, or around ArteLuta Capoeira and/or while using any ArteLuta Capoeira facilities, tools, equipment, or materials.

I agree to indemnify, defend, and hold harmless the Released Parties from and against any and all costs, expenses, damages, claims, lawsuits, judgments, losses, and/or liabilities (including attorney fees) arising either directly or indirectly from or related to any and all claims made by or against any of the Released Parties due to bodily injury, death, loss of use, monetary loss, or any other injury from or related to my use of ArteLuta Capoeira facilities, tools, equipment, or materials, whether caused by the negligence of the Released Parties or otherwise specifically related to COVID-19.

By indicating Yes below I acknowledge and represent that I have read the foregoing Waiver of Liability, understand it and sign it voluntarily as my own free act and deed, including without limitation the Release of Liability and Indemnification requirements contained in this document; I am sufficiently informed about the risks involved in using ArteLuta Capoeira’s facilities to decide whether to sign this document; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; and I execute this document for full, adequate, and complete consideration fully intending to be bound by the same. I agree that this Waiver of Liability shall be governed by and construed in accordance with CA law, and that if any of the provisions hereof are found to be unenforceable, the remainder shall be enforced as fully as possible and the unenforceable provision(s) shall be deemed modified to the limited extent required to permit enforcement of the Waiver of Liability as a whole.

This waiver remains in effect until the State of CA lifts all COVID-19 related mandates.
Click Yes to indicate that you have read, understand and agree to our Assumption of Risk and Waiver of Liability Relating to Coronavirus (COVID-19). *
Click submit to complete your Participant Acknowledgement & Release forms.
A copy of your responses will be emailed to the address you provided.
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