Pre-eval Waiver

Date of your scheduled pre-evaluation or trial class:*

Why is now a good time to start karate?*

Student's Name*

First Last

Date of Birth*

MM

DD

YYYY

Name of school child attends*

Name of nanny or sitter

What other activities is your child involved in?*

What are the 3 main reasons you are signing up your child for Karate?*

Any medical problems? If yes, please list.*

On any medication? If yes, please list.*

Any allergies or allergic to any medication? If yes, please list.*

No exercise program should be undertaken without the expressed clearance of a physician. The subscriber agrees to hold harmless Atlanta Kick, its staff, officers, and students, for any aggravation of a pre-existing health condition, whether or not disclosed above. The subscriber certifies that the above information is true and complete.

Parent Information

Parent(s) Names*

Email*

Best Phone*

Parent(s) Occupation*

Address*

Street Address City ZIP / Postal Code

How did you hear about us?*

Waiver

Notice on State Licensing All programs for age 17 or younger (Karate, Crossfit, Other) work on 5 (five) approximately 10-week sessions per year. Even if you pay monthly, you’re not obligated to continue for future sessions beyond your current agreement. Classes are 2-3 times per week, and 30 minutes each for younger children, and 45 minutes each for older children. I have been advised and I understand that these programs are not licensed by the State of Georgia, and is exempt from licensing. Signatory, for myself and/or any persons being registered (“Participant”), that I have had an opportunity to observe the programs offered and that the Participant is physically and mentally able to take classes offered by AK in any program in which the Participant may participate. I understand and agree that strict observation of our rules and regulations and the rules and regulations relative to training, including but not limited to the use of protective equipment, is required. By signing this agreement, signatory and participant agree to fully and completely comply with all terms and conditions hereof and our rules and regulations. Failure to comply with rules and regulations is grounds for immediate suspension or termination of membership. I understand and agree that the Participant’s use of and presence at Atlanta Kick’s facilities are at the sole, exclusive risk of the Participant. I, and the Participant, are fully aware and agree that martial arts and other physical training involves skills and training which include violent and sudden movements, contact between instructors and participants and between and among participants and that such contact may result in personal injury, or death to the Participant, despite precautions taken to avoid such injuries. I warrant that I have authority to and hereby consent for Participant to engage in such contact as may be necessary or required by the Participant’s participation in the training program and/or classes, and I assume all risks. Member, on behalf of him/herself, the Participant, and/or anyone claiming by or through the Member and/or the Participant, hereby holds harmless, releases, indemnifies, covenants not to sue and forever discharges Atlanta Kick and its officers, directors, employees, instructors, agents, operators and authorized representatives (“AK”) from any liability, claim, loss and/or expense, including loss of property, personal injury, disability, death, incurred by the Member and/or the Participant and arising from the Participant’s participation in any program offered by Atlanta Kick, whether caused by Atlanta Kick, its instructors, participants, agents, employees, operators, or authorized representatives. I hereby certify that I am at least 18 years of age, sui juris, and competent to enter into this Agreement under Georgia law. I, the undersigned acknowledge that participants signed for have no physical impairments or illnesses that will endanger themselves or others. Release: In consideration of the above mentioned risks and hazards and in consideration of the fact that I am (or participants are) willingly and voluntarily participating in the activities available at CrossFit, AK CrossFit, and Atlanta Kick, I, the undersigned hereby release CrossFit, AK CrossFit, and Atlanta Kick, their principals, agents, employees, and volunteers from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my participation in this activity, including those allegedly attributed to the acts or omissions of the above mentioned parties. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full legal force and effect. If I am signing on behalf of a minor child, I also give full permission for any person connected with CrossFit, AK CrossFit, and Atlanta Kick to administer first aid deemed necessary, and in case of serious illness or injury, I give permission to call for medical and or surgical care for myself or a child and to transport same to a medical facility deemed necessary for the well being of the child. We and those acting under our authority reserve the right to use photographs, videotapes, artwork or other likenesses of the member for marketing, publishing or any other lawful purposes. without compensation to you or your child. Member understands and agrees that emails, SMS messages, and similar related to our programs and other related topics will be sent to the addresses and numbers provided. Indemnification: Signatory accepts financial responsibility for any injury that the participant may cause either to him/herself or to any other participant due to his/her (or participant’s) negligence. Should the above mentioned parties, or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to reimburse them for such fees and costs If I am a parent or guardian, I agree to indemnify AK for any and all costs related to any action, risks, or conditions released, assumed or acknowledged in this agreement. I have read and understood the foregoing assumption of risk, and release of liability and indemnification and I understand that by signing it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my (or participant’s) negligent or intentional act or omission. I understand that by signing this form I am waiving valuable legal rights.*

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