APEX martial arts
Waiver
Waiver For?
MySelf
My Child/Dependent
First Name
LastName
DOB
Primary Phone
Secondary Phone
NA
Female
Male
Gender
Emerg. Contact/Parent Name
Emerg. Phone/Parent Phone
Email Address
How did you Hear About Us?
Please select
Google
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Referred By Friend
Other
Do you have any Medical Concerns?
No/Yes(Please List)
Yes
No
(if yes, you must submit a doctor's note specifically stating you are fit to participate in a high intensity fitness workout)
Please list your medical concerns
I confirm that I am the legal guardian and authorize him/her to join
APEX martial arts
.
RELEASE OF CLAIMS ARISING FROM ACCIDENT
Signature Here Please
Draw
Erase
Clear
Electronic Signature Consent *
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.