Poolesville Self Defense Training Questionnaire, Fitness Release and Waiver of Liability

Poolesville Self Defense Training Session Questionnaire, Fitness Release and Waiver of Liability

Please Complete the Information Below
Full Name of participant *

First Name Last Name
Full Name of participant (if applicable)

First Name Last Name
Full Name of participant (if applicable)

First Name Last Name
Name of parent or guardian (if participant is under 18 years of age)

First Name Last Name
Birth Date *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Emergency Phone Number *

Area Code Phone Number
E-mail *
MEDICAL HISTORY (Complete at your discretion. We will not share your information with anyone)
Have you had any family history of chronic disease (heart disease, diabetes, etc.)? *
If yes, please list
Have you ever been diagnosed or treated for any chronic disease including asthma? *
If yes, please list
Are you currently taking any medication? *
If yes, please list
Any other conditions that we need to be aware of (i.e. Past or present injuries, allergies, etc)? *
If yes, please list
PERSONAL DETAILS
If you have answered YES to any of the above questions, you must obtain a medical clearance prior to carrying out a physical exercise program.
Do you participate in any sport or recreation activities? *
Do you have a physically demanding job? *
What is your level of experience with Brazilian Jiu-Jitsu, Thai Boxing, Gymnastics or Fitness Programs? *
RELEASE and LIABILITY WAIVER

Please read carefully before submitting form.
Release: We, the student and guarantor, if applicable, on behalf of ourselves, members of our family, our heirs, executors, administrators, and assigns, hereby forever release, discharge, and hold harmless, Poolesville Self Defense LLC, RPC Fitness LLC, Mark Munster and Ray Castro, their families, or any representatives or agents, Fishpool LLC., the property owner/landlord for any injury, loss, or damage to my person or property howsoever caused, arising out of or in connection with my taking part in personal training sessions or martial arts classes, seminars and activities and notwithstanding that the same may have been contributed to or occasioned by the negligence of Poolesville Self Defense LLC, RPC Fitness LLC, Mark Munster, Ray Castro, their families, or any representatives or agents, Fishpool LLC or the property owner/landlord. Please note participant must supply their own protective equipment.
By checking the box below, you willfully acknowledge and agree to the above release and liability waiver *

I Agree
Signature *

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Poolesville Self Defense Training Session Questionnaire, Fitness Release and Waiver of Liability