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The MMA Room - Waiver Form

Student name: {name}

Date of Birth: {dob}

Address: {address}

Telephone Number: {phone} 

Medical Information

1. Do you have any history of heart trouble?                              Yes No  
2. Have you ever experienced pain or tightness in your chest? Yes No  
3. Have you ever had a stroke?                                                  Yes No  
4. Do you have high or low blood pressure?                               Yes No  
5. Do you often suffer from severe dizziness?                            Yes No  
6. Do you have diabetes?                                                            Yes No  
7. Are you pregnant?                                                                   Yes No  

If you answer ‘Yes’ to any of the above questions, you will need a doctor’s release to use the clubs

classes and facilities.

Emergency Contact Name: {contact_name}

Emergency Contact Telephone: {contact_phone}                                                                                                                       

Emergency Contact Relationship: {contact_relation}

ASSUMPTION OF RISK & WAIVER OF LIABILITY: Visitor/Member represents that he/she is in good physical condition and is able to use the facilities of The MMA Room. Visitor/Member hereby acknowledges that he/she is fully aware of the risks and hazards inherent in the practice of martial arts and in fitness activities and hereby assumes voluntarily all and any risks of loss, damage or injury that may be sustained by Visitor/Member or to his/her property.

Visitor/Member hereby accepts full responsibility for the use of, or participation in, any and all classes, services, equipment, demonstrations or events, whatsoever owned, operated or sponsored by The MMA Room, whether on-site or off-site and hereby releases and agrees to hold harmless, The MMA Room, its owners, officers, directors, members, employees, representatives and agents from any and all loss, claim, injury, damage or liability sustained or incurred by Visitor/Member resulting there from. This release shall be binding upon the heirs, distributes, next of kin, executor and administrator of each of the undersigned.

By signing below, you explicitly consent to us processing the personal data you have included in this form in accordance with our Privacy Policy that is set out in the adjacent document.

In signing this Agreement, the undersigned hereby acknowledges and represents that that he/she has read this release, understands it and signs it voluntarily.

Visitor / Member Name:

 or

Parent / Guardian (if under 18 years):

Date: {sign_date}