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MOUSEL'S SELF-DEFENSE ACADEMY AGREEMENT AND RELEASE FORM

This AGREEMENT, made and entered into this date: October 16, 2018 by and between MOUSEL'S SELF-DEFENSE ACADEMY (School), and (Student, You, Your, He, or She).
That whereas Student desires to participate in a martial arts/self-defense course and School is engaged in various styles of martial arts; School and Student agree as follows;

1. By signing this AGREEMENT in the space provided below, you fully acknowledge that you have read and do understand each and every paragraph contained herein. Your acceptance to the School is contingent upon your understanding and acknowledgment of this statement. Do not sign this AGREEMENT if you do not understand any portion of it or if you are in disagreement with any statement contained herein.

2. Student here acknowledges that he or she is aware of the fact that the martial arts and selfdefense involve a greater potential for accident and injury than many other sports. Injuries (bruises, sprains, etc.) are a very likely occurrence and there is a possibility of serious injury such as broken bones, brain damage and death. Student here specifically states that he or she assumes the risk and danger of accident and injury which may result from taking part in any exercises, practices or demonstrations of said martial arts and hereby releases School, its agents and instructors, including, Tim Mousel, fellow students, from any and all liability or responsibility for and injury or damage incurred by the Student during the period the Student is taking instructions from the School. Student further agrees that School, its agents and instructors shall not be liable for any items of personal property lost, damaged, stolen or destroyed while on School's premises, or while taking part in School related martial arts activities off the premises.

3. Student promises and covenants not to institute any legal action or to permit same to be brought on his or her behalf, either directly or indirectly, on account of the occurrence of any claimed personal injuries or damages, or on account of loss of property, to Student, and agrees to save, indemnity and hold harmless and defend at his or her sole expense, School and any instructors therein, including Tim Mousel from any demands or causes of action which may now or in the future be asserted against the aforesaid parties arising out of any events occurring during the course of instruction or demonstration. Student recognizes that his or her assumption or risk and covenant not to sue are fully applicable in respect to any and all of Student's full or part-time instructors, as well as School itself.

4. Student acknowledges that he or she is over eighteen (18) years of age, of sound mind, and are authorized and capable of making this AGREEMENT having first read it carefully. The Student hereto acknowledges that this written AGREEMENT is the entire agreement of the parties relative to the School. Any agreement that in any way varies the terms of this AGREEMENT shall be unenforceable and completely void unless such agreement is in writing and signed by both parties.

Student acknowledges receipt of a fully executed copy of this AGREEMENT and acknowledges reading this AGREEMENT carefully before signing.

EXECUTED this the day of: October 16, 2018

First Student's Name

First Name*

Last Name*

Phone*
First Student's Date of Birth*
First Student's Information

Employer:
1. How did you hear about us?
Internet
Referral
Other
Facebook
Google
Website

If Other or Referral, please list:
3. Do you have any medical problems that the instructor should be aware of?*

If Yes, please list:

4. In case of emergency notify: *

Relationship: *

Phone: *

Mousel's Self-Defense Academy reserves all rights to dismiss any students, at any time, for misconduct or actions which may convey a bad image.

First Student's Signature*
Second Student's Name

First Name*

Last Name*
Second Student's Date of Birth*
Second Student's Information

Employer:
1. How did you hear about us?
Internet
Referral
Other
Facebook
Google
Website

If Other or Referral, please list:
3. Do you have any medical problems that the instructor should be aware of?*

If Yes, please list:

4. In case of emergency notify: *

Relationship: *

Phone: *

Mousel's Self-Defense Academy reserves all rights to dismiss any students, at any time, for misconduct or actions which may convey a bad image.

Third Student's Name

First Name*

Last Name*
Third Student's Date of Birth*
Third Student's Information

Employer:
1. How did you hear about us?
Internet
Referral
Other
Facebook
Google
Website

If Other or Referral, please list:
3. Do you have any medical problems that the instructor should be aware of?*

If Yes, please list:

4. In case of emergency notify: *

Relationship: *

Phone: *

Mousel's Self-Defense Academy reserves all rights to dismiss any students, at any time, for misconduct or actions which may convey a bad image.

Fourth Student's Name

First Name*

Last Name*
Fourth Student's Date of Birth*
Fourth Student's Information

Employer:
1. How did you hear about us?
Internet
Referral
Other
Facebook
Google
Website

If Other or Referral, please list:
3. Do you have any medical problems that the instructor should be aware of?*

If Yes, please list:

4. In case of emergency notify: *

Relationship: *

Phone: *

Mousel's Self-Defense Academy reserves all rights to dismiss any students, at any time, for misconduct or actions which may convey a bad image.

Fifth Student's Name

First Name*

Last Name*
Fifth Student's Date of Birth*
Fifth Student's Information

Employer:
1. How did you hear about us?
Internet
Referral
Other
Facebook
Google
Website

If Other or Referral, please list:
3. Do you have any medical problems that the instructor should be aware of?*

If Yes, please list:

4. In case of emergency notify: *

Relationship: *

Phone: *

Mousel's Self-Defense Academy reserves all rights to dismiss any students, at any time, for misconduct or actions which may convey a bad image.

Sixth Student's Name

First Name*

Last Name*
Sixth Student's Date of Birth*
Sixth Student's Information

Employer:
1. How did you hear about us?
Internet
Referral
Other
Facebook
Google
Website

If Other or Referral, please list:
3. Do you have any medical problems that the instructor should be aware of?*

If Yes, please list:

4. In case of emergency notify: *

Relationship: *

Phone: *

Mousel's Self-Defense Academy reserves all rights to dismiss any students, at any time, for misconduct or actions which may convey a bad image.

Seventh Student's Name

First Name*

Last Name*
Seventh Student's Date of Birth*
Seventh Student's Information

Employer:
1. How did you hear about us?
Internet
Referral
Other
Facebook
Google
Website

If Other or Referral, please list:
3. Do you have any medical problems that the instructor should be aware of?*

If Yes, please list:

4. In case of emergency notify: *

Relationship: *

Phone: *

Mousel's Self-Defense Academy reserves all rights to dismiss any students, at any time, for misconduct or actions which may convey a bad image.

Eighth Student's Name

First Name*

Last Name*
Eighth Student's Date of Birth*
Eighth Student's Information

Employer:
1. How did you hear about us?
Internet
Referral
Other
Facebook
Google
Website

If Other or Referral, please list:
3. Do you have any medical problems that the instructor should be aware of?*

If Yes, please list:

4. In case of emergency notify: *

Relationship: *

Phone: *

Mousel's Self-Defense Academy reserves all rights to dismiss any students, at any time, for misconduct or actions which may convey a bad image.

Ninth Student's Name

First Name*

Last Name*
Ninth Student's Date of Birth*
Ninth Student's Information

Employer:
1. How did you hear about us?
Internet
Referral
Other
Facebook
Google
Website

If Other or Referral, please list:
3. Do you have any medical problems that the instructor should be aware of?*

If Yes, please list:

4. In case of emergency notify: *

Relationship: *

Phone: *

Mousel's Self-Defense Academy reserves all rights to dismiss any students, at any time, for misconduct or actions which may convey a bad image.

Tenth Student's Name

First Name*

Last Name*
Tenth Student's Date of Birth*
Tenth Student's Information

Employer:
1. How did you hear about us?
Internet
Referral
Other
Facebook
Google
Website

If Other or Referral, please list:
3. Do you have any medical problems that the instructor should be aware of?*

If Yes, please list:

4. In case of emergency notify: *

Relationship: *

Phone: *

Mousel's Self-Defense Academy reserves all rights to dismiss any students, at any time, for misconduct or actions which may convey a bad image.

Student's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive class/schedule updates by email
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Employer:
1. How did you hear about us?
Internet
Referral
Other
Facebook
Google
Website

If Other or Referral, please list:
3. Do you have any medical problems that the instructor should be aware of?*

If Yes, please list:

4. In case of emergency notify: *

Relationship: *

Phone: *

Mousel's Self-Defense Academy reserves all rights to dismiss any students, at any time, for misconduct or actions which may convey a bad image.

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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