Ultimate Martial Arts & Fitness Inc 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 Ultimate Martial Arts & Fitness Inc.

RELEASE OF CLAIMS ARISING FROM ACCIDENT

I (we) (the releaser, which term includes my heirs, executors, administrators, and assigns), in consideration of my acceptance as member of Ultimate Martial Arts (Ultimate Martial Arts & Fitness Inc.) (the releases, which term includes the heirs, executors, administrators and assigns of the releasees), from all manner of actions, causes of action, claims or demands which I, the releaser, now have or may hereafter have against the releasees, in any way arising out of an accident occurring on or about the premises of Ultimate Martial Arts (Ultimate Martial Arts & Fitness Inc.) whether or not occasioned by the negligence of the releasees. I (we) acknowledge that any prior or medical history, or condition that arises after signing this release form, that may affect my health pr physical well-being, or the health or physical well being of another party (including pregnancy) while participating in the programs at Ultimate Martial Arts (Ultimate Martial Arts & Fitness Inc.) must be disclosed in writing and signed by the club Owner before attending classes. The club Owner reserves the right to freeze, or terminate the parties membership based on this information.

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.