Signature |
KICK-ROBICS |
American Academy of Self Defense 3345 Kimber Dr., Newbury Park, CA 91320 (805) 499-1799 |
Questionaire |
Date |
Emergency Contact |
Emerg. # |
I, |
have chosen to participate in the American Academy of Self Defense |
program of Kick-Robics. I hereby waive any claim I may have at any time against American Academy of Self Defense. |
Regarding any personal injury or damage I may suffer or incur by such participation, I have been advised that participation in American Academy of Self Defense's Martial Arts and exercise program may result in abnormal blood pressure, fainting, disorders of the heartbeat, rare instances of heart attack, broken bones, and muscle tearing. I hereby accept these risks. To my knowledge, I do not have any limiting physical condition or disability that would preclude my participation in American Academy of Self Defense's Martial Arts & exercise program and further certify that I have fully and accurately completed all forms submitted to me by American Academy of Self Defense intended to disclose any such limiting physical conditions or disability. I also understand that a physician's examination should be obtained by all participants prior to involvement in the exercise/Martial Arts program. If the participant refuses to obtain a physician's permission, he/she must sign the following statement: |
I, |
approval for participation in a progressive exercise/Martial Arts program. I fully understand the strenuous nature of this program. I accept the complete responsibility for my health and well being in the voluntary exercise/Martial Arts program and related testing. I understand that no responsibility is assumed by American Academy of Self Defense or the leaders of the exercise/Martial Arts program. |
have been informed that it is advisable for me to obtain a physician's |
Submit On-line or, print this page, sign it, and bring it to your first class. You may also fax it to (XXX) XXX-XXXX |
