Sina de Capoeira Class Registration Form
SINA DE CAPOEIRA – PARTICIPANT INFORMATION / RELEASE OF LIABILITY
This form is used to collect contact information and as a liability waiver, where, by after you read and sign, you agree to all terms listed. This information is confidential and will not be exchanged with anyone outside of the school for any reason.
Email *
Participant name (first and last): *
Parent name (if applicable):
Sex:
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Date of birth: *
MM
/
DD
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YYYY
Phone: *
Street address: *
Apartment number:
City: *
ZIP code: *
How did you hear about Sina de Capoeira? *
Why are you interested in Capoeira? *
Required
Emergency contact name: *
Emergency contact relationship:
 *
Emergency contact email:
 *
Emergency contact phone:
 *
Emergency contact insurance carrier:
 *
Emergency contact insurance policy/group number:
 *
Current medications, medical conditions, and/or allergies:
Physical ailments or other concerns:
Capoeira name (if applicable):
Belt (if applicable):
Group/teacher/location (if applicable):
RELEASE OF LIABILITY:

"I, for myself, assigns, heirs, next of kin acknowledge and those under my guardianship agree that I understand the nature of sports activities and that I am qualified, in good health, and in proper physical condition to participate in such activities as they occur at the Sina de Capoeira academies, events, and any other gatherings organized by and / or related to said organization. I further agree and warrant that if at any time I believe these conditions to be unsafe, I will immediately discontinue further participation in these
activities. I fully understand that sports involve risks and dangers of serious bodily injury, including permanent disability, paralysis and death. I understand that these risks and dangers may be caused by my own actions or inactions, the actions or inactions of others and / or the condition in which the activities take place. I understand that there may be risks and social and economic losses
either not known to me or not readily foreseeable at this time and I fully accept and assume all such risks and responsibility for losses, costs and damages that I may incur as a result of the participation the activities. I hereby release, discharge and hold harmless Sina de Capoeira, their respective owners, lease holders, administrators, directors, agents, officers, members, volunteers, and employees, other participants, sponsors and advertisers from all liability, claims, demands, losses and / or damages caused, or alleged to be caused, in whole or in part by me or by my assigns, heirs, next of kin, and those under my guardianship. Furthermore, I will indemnify, save and hold harmless Sina de Capoeira from any litigation expenses, attorney fees, loss, liability, damage, or costs which may be incurred as the result of such a claim. Furthermore, I also agree that participation grants Sina de Capoeira and its agents the right to take and utilize photographs without any legal or financial obligation.

I have read this agreement, fully understand its terms and have signed it freely and without inducement. Shall any portion of this agreement be held to be invalid the balance, notwithstanding, shall continue in full force and effect."

By typing your first and last name below, you acknowledge and affirm the above.
 *
A copy of your responses will be emailed to .
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