Student Name *

First Name

Last Name

Date of Birth *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Terms *

Assumption of Risk and Waiver of Liability Students represent that he/she is in good physical condition and is able to use the facilities of Soul Fighters Midlothian. Student and Soul Fighters Midlothian acknowledges that he/she is fully aware of the risks and hazards in the practice of martial arts and hereby assumes voluntarily all risks of loss, damage, or injury (including death) that may be sustained by student or to his/her property. Student hereby accepts full responsibility for the use of, or participation in, any and all classes, services and equipment, demonstrations or events, whatsoever owned, operated by Soul Fighters Midlothian. Whether on site or off site and hereby releases and agrees to hold harmless Soul Fighters Midlothian, it’s owners, officers, directors, and members, employees, and representatives from any and all loss, claim, injury, damage or liability sustained or incurred by student resulting there from. This release shall be binding upon the heirs, distributes, next of kin, executor and administrator of each of the undersigned. In signing this agreement electronically below and checking the box below, the undersigned hereby acknowledges and represents that he/she has read this release, understands it and signs it voluntarily.

I agree to the above terms.

Additional Member Name

First Name

Last Name

Date of Birth

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Additional Member Name

First Name

Last Name

Date of Birth

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Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

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Today's Date *

MM

DD

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