New Student Information
Gingarte Capoeira Chicago
First Name *
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Last Name *
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We have several class locations. Where do you plan on attending?
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Telephone Number
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Mailing Address
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Email Address *
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Would you like to be added to our newsletter? *
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Emergency Contact Name *
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Emergency Contact Phone Number *
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How did you hear about us? *
Check all that apply. If you found a flyer, please specify where.
Acceptance of Risk
As a participant in CAPOEIRA CHICAGO activities, I recognize and acknowledge that capoeira is a martial art involving strenuous exercise and physical training that can result in certain risks of physical injury including, but not limited to, muscle and ligament injuries, broken bones, nerve damage and death which may arise from falls, contact with another person or object or other causes.

I agree to assume full responsibility for any injuries, damage or loss that may be connected or associated with CAPOEIRA CHICAGO.

I hereby release, wave and discharge CAPOEIRA CHICAGO and ITS INSTRUCTORS, from any and all liability, claim, damages and losses arising out of any loss, damage or injury that may be sustained by me or to any property belonging to me while participating in CAPOEIRA CHICAGO activities.

I acknowledge that CAPOEIRA CHICAGO is providing me with an educational, cultural and athletic opportunity, and I agree to indemnify and hold CAPOEIRA CHICAGO harmless for any occurrence resulting there from.

It is my express intent that this ACCEPTANCE OF RISK agreement shall bind the members of my family, my heirs and assigns. This agreement shall be construed in accordance with the laws of the State of Illinois. I further agree that participation in any activity will be at my own discretion and judgement. I have read and fully understand the above ACCEPTANCE OF RISK and I voluntarily sign this Agreement.

After reading the above Agreement, please select one: *
Are you over the age of 18? *
Please provide your initials as a digital signature to this Agreement. *
(Parent/Guardian must provide initials if participant is a Minor)
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