RB Capoeira Kids’ Registration
Student's Name *
Are you a current student? *
Date of Birth *
Parent's Name *
Address *
Parent's Phone *
Alternate Emergency Contact *
Relationship *
Alternate Emergency Phone *
Which class are you registering for? *
How would you like to pay? *
Acknowledgment of program participation responsibility, express assumption of risk, release of liability
I hereby agree to the following: Member is aware that participation in any activity or physical activity may result in accident or injury, and assumes the risk connected with the participation in an activity or exercise and represents that the Member is in good health and suffers from no physical impairment, which would limit their use of the RB Capoeira facility.

Member acknowledges that Raizes do Brasil Capoeira will not render any medical services including medical diagnosis or Member's physical condition. Member specifically agrees that Raizes do Brasil Capoeira, its officers, employees, and agents shall not be liable for any claim, demand, cause or 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 Member's use of the facility or participationin any sport, exercise or activity within or without the center's premises, and member agrees to hold Raizes do Brasil Capoeira harmless from same.

I hereby affirm that I have read and fully understand the above. *
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