Name: {name} Date of Birth: {dob}
Address: {address}
Phone: {phone}
I, the undersigned, understand that the study and practice of strength and conditioning exercises and Brazilian Jiu Jitsu requires physical contact in many contexts, including, but not limited to, sparring, drilling, Olympic lifting, and learning techniques. I also understand that injury, including death, maiming, or paralysis, or other serious injury, is an inherent risk or potential result of any such activity. I represent that I am medically and physically able to participate in the exercises and physical demands of the martial arts and strength and conditioning classes. I also agree to immediately make known to the instructor any injuries or physical limitations. I also understand that there is no guarantee of my personal safety after the completion of these classes. In view of the foregoing, and as a term and condition of being a student/client of NOVA MARTIAL ARTS, LLC, I, with the intention of binding myself, my spouse, heirs, legal representatives, and assigns, expressly release and discharge Jason Plaisted, their heirs and legal representatives, NOVA MARTIAL ARTS, LLC instructors, from all claims, demands, actions, judgments, and executions that I, ever had, or now has, or may have, or that anyone claiming through myself may have, or claim to have, against Kevin Sawyer and Jason Plaisted, their heirs or representatives, NOVA MARTIAL ARTS, LLC instructors, created by, or arising out of any and all class activity regardless of where held or when held.
I hereby authorize the staff members NOVA MARTIAL ARTS, LLC to act for me according to their best judgment in any emergency requiring medical attention, and I hereby waive and release NOVA MARTIAL ARTS, LLC and their affiliates from any and all liability for any injuries or illnesses while going to and from and while at NOVA MARTIAL ARTS, LLC. All medical expenses incurred will be the responsibility of the participant.
Publicity Release: I give permission for my image in the form of a photo to be used by NOVA MARTIAL ARTS, LLC for advertising or marketing purposes.
I have read this release and waiver of liability, assumption of risk and indemnity agreement, fully understand its terms, and have signed it freely and voluntarily without any inducement, assurance, or guarantee being made to me and intend my signature to be complete and unconditional release of all liability to the greatest extent allowed by law.
In witness whereof, I execute this release on the day and year first written below.
Signature: . Date: {sign_date}