Westside Muay Thai Waiver

Waiver For? MySelf My Child/Dependent

First Name

LastName

DOB

Primary Phone

Secondary Phone

Gender

Emerg. Contact/Parent Name

Emerg. Phone/Parent Phone

Email Address

How did you Hear About Us?

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 Westside Muay Thai.

RELEASE OF CLAIMS ARISING FROM ACCIDENT

ASSUMPTION OF RISKS. I understand that the World Health Organization has classified the COVID-19

outbreak as a pandemic. I further understand that COVID-19 is a highly contagious and dangerous

disease, and that contact with the virus that causes COVID-19 may result in significant personal injury

or death.

I understand and accept that while (CLUB) has undertaken the required steps as indicated by the

department public health to lessen the risk of transmission of COVID-19 in connection with the

programs and services the (CLUB) is not responsible in any manner for any risks related to COVID-19 in

connection with the club.

I am fully aware and accept all risks that participation at (CLUB) carries with it inherent risks related to

COVID-19 transmission (“Inherent Risks”) that cannot be eliminated regardless of the care taken to

avoid such risks. Inherent Risks may include, but are not limited to, (1) the risk of coming into close

contact with individuals or objects that may be carrying COVID-19; (2) the risk of transmitting or

contracting COVID-19, directly or indirectly, to or from other individuals; and (3) injuries and

complications ranging in severity from minor to catastrophic, including death, resulting directly or

indirectly from COVID-19 or the treatment thereof.

Further, I understand and accept that the risks of COVID-19 are not fully understood, and that contact

with, or transmission of, COVID-19 may result in risks including but not limited to loss, personal injury,

sickness, death, damage, and expense, the exact nature of which are not currently ascertainable, and

all of which are to be considered Inherent Risks.

I hereby voluntarily accept and assume all risk of loss, personal injury, sickness, death, damage, and

expense arising from such Inherent Risks. Furthermore, I represent and warrant that I do not suffer

from any medical condition or disease that might in any way hinder or prevent me from receiving the

Services, including, to my knowledge, COVID-19. I hereby agree to contact (CLUB) immediately for any

of the following (1) I contract COVID-19; (2) I was in contact with anyone that contracted COVID-19); I

experience any of the following Flu Symptoms, Sore Throat, Vomiting, Cough, Tiredness and Fever.

Signature Here Please

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.