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Refuge Martial Arts

347 North Merrick Avenue Ozark, Alabama 36360

301 Main Street Headland, Alabama 36345

I am aware that the practice of martial arts can be physically stressful or dangerous and in certain instances can even be harmful and result in injury or death. I am also aware that strenuous physical activity such as is involved in the Refuge Martial Arts classes, activities, or practice sessions (collectively, the “classes”), may pose a health risk to certain individuals, including but not limited to those individuals who have, or have ever had the following medical conditions, or who have the following conditions in their family histories: elevated blood pressure, cardiac (heart) problems, diabetes, orthopedic problems. 

I am also aware that strenuous physical activity can pose health risks to people who smoke, who are overweight or obese, who are of advanced age, or who are pregnant or who have recently given birth. I understand that I should consult with my personal physician, and obtain his or her consent, before I begin or continue to participate in the classes. 

I am not relying on the Refuge Martial Arts organization or any of its agents or representatives to determine whether participation in the classes are medically or otherwise appropriate for me. 

I understand that my participation in the classes is voluntary and at my own risk and that no special supervision or monitoring, medical or otherwise, will be provided. In consideration for my being permitted to participate in the classes I hereby agree on behalf of myself, my heirs, successors, administrators and assigns, to release, and hereby release to the extent permitted by law, Refuge Martial Arts, its officers, directors, agents, employees, volunteers, administrators or assigns, from any and all complaints, claims, damages, claims for attorneys’ fees, or causes of action of any kind, including but not limited to any personal injury or other claims arising from or out of my participation in the classes.

I further agree not to sue or make any claim of any nature whatsoever in any court, agency, or other forum or proceeding against Refuge Martial Arts, or any other individual or entity who I have released and agreed to hold harmless in the preceding sentence. I have read this form and understand it. 

I have had the opportunity to ask questions and consult with an attorney of my own choosing about the waiver and release contained in this form. I am signing the form voluntarily and of my own free will. I have sufficient information to give my informed consent to participate in the classes. 

Sign and Print Names:

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Participant Date

X____________________________________________________________________________________

Parent or Guardian if Participant under 18 Date

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• {...} - Full name
• {...} - Date of birth
• {...} - Member address
• {...} - Phone number
• {...} - Document duration in months
• {...} - Emergency contact (if member has any)
• {...} - Emergency contact phone
• {...} - Emergency contact relation
• {...} - Date document was signed (if applicable)
• {...} - Name of the member or guardian signing the document (if applicable)
• - Member clicks to add their initials

Refuge Martial Arts Representative Date