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Participant Agreement and
Release of Liability/Waiver

COVID-19 Policies & Vaccination Self-Attestation

Prior to taking an Impact Bay Area class all participants must complete a Release of Liability/Waiver. All individuals under the age of 18 MUST have waiver signed by a Parent or Legal Guardian. Minors under the age of 18 without a waiver signed by a Parent or Legal Guardian will not be allowed to participate in class.

This agreement is between Participant and Impact Bay Area, its employees, and affiliated organizations, their agents, employees, volunteers, officers and directors (collectively referred to as "Impact").

In consideration for participation in any Impact course (hereinafter referred to as the "Course"), I make the following statements, promises and agreements on behalf of myself and, if applicable, my child or ward:

  1. I am aware that the course involves strenuous physical activities and personal body contact, and that I may be participating in simulated assault scenarios which can be physically harmful and/or emotionally stressful.
     
  2. I attest that above named participant is physically fit to participate in the Course.
     
  3. I am voluntarily taking the Course with knowledge of the danger involved, and I agree to accept any and all risks of injury.
     
  4. I understand that if above named participant has a disability, illness, pregnancy, or is currently seeing a therapist or other health care provider (physician, social worker, psychotherapist, chiropractor, podiatrist, clinical psychologist, or the like), I am required to consult with said physician or health care provider both before and during participation in the course. Further, I acknowledge that Impact strongly recommends that I continue with treatment of each and every current or recent physical or emotional condition and that I consult with each health care provider for the duration of the course.
     
  5. I hereby release and discharge Impact Bay Area and its officers, employees, volunteers, agents, and contractors from all actions, claims, or demands that I, my heirs, guardians, and legal representatives now have, or may have in the future, for injury or damage resulting from participation in the Course.

By signing below, I confirm that I have read, understand, and consent to the terms of this waiver agreement. I warrant that I am not relying on any oral representations, statements or inducement apart from the statements made on this form.

---

Date: January 28, 2023

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Emergency Medical Release Form

This form is required for participation in all Impact Bay Area Classes.
Please complete each section thoroughly, sign and date.

Gender:*
Allergies - Does your child have any allergies to food, medications, insects, etc.?*
No
Yes

Health Conditions - Has your child, currently or in the past, been diagnosed with any of the following health conditions:

Asthma*
No
Yes
Diabetes*
No
Yes
Heart Problems*
No
Yes
Vision/Hearing Problems*
No
Yes
Epilepsy/Seizure Disorder*
No
Yes
Frequent Migraine Headaches*
No
Yes
Attention Deficit-Hyperactivity*
No
Yes
Chronic Ear Infections*
No
Yes

If Yes, please explain:

List any other health condition(s) not listed above:

List any medication(s) currently taken by your child:
First Participant's Signature*
Second Participant's Name

First Name*

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

Emergency Medical Release Form

This form is required for participation in all Impact Bay Area Classes.
Please complete each section thoroughly, sign and date.

Gender:*
Allergies - Does your child have any allergies to food, medications, insects, etc.?*
No
Yes

Health Conditions - Has your child, currently or in the past, been diagnosed with any of the following health conditions:

Asthma*
No
Yes
Diabetes*
No
Yes
Heart Problems*
No
Yes
Vision/Hearing Problems*
No
Yes
Epilepsy/Seizure Disorder*
No
Yes
Frequent Migraine Headaches*
No
Yes
Attention Deficit-Hyperactivity*
No
Yes
Chronic Ear Infections*
No
Yes

If Yes, please explain:

List any other health condition(s) not listed above:

List any medication(s) currently taken by your child:
Third Participant's Name

First Name*

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

Emergency Medical Release Form

This form is required for participation in all Impact Bay Area Classes.
Please complete each section thoroughly, sign and date.

Gender:*
Allergies - Does your child have any allergies to food, medications, insects, etc.?*
No
Yes

Health Conditions - Has your child, currently or in the past, been diagnosed with any of the following health conditions:

Asthma*
No
Yes
Diabetes*
No
Yes
Heart Problems*
No
Yes
Vision/Hearing Problems*
No
Yes
Epilepsy/Seizure Disorder*
No
Yes
Frequent Migraine Headaches*
No
Yes
Attention Deficit-Hyperactivity*
No
Yes
Chronic Ear Infections*
No
Yes

If Yes, please explain:

List any other health condition(s) not listed above:

List any medication(s) currently taken by your child:
Fourth Participant's Name

First Name*

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

Emergency Medical Release Form

This form is required for participation in all Impact Bay Area Classes.
Please complete each section thoroughly, sign and date.

Gender:*
Allergies - Does your child have any allergies to food, medications, insects, etc.?*
No
Yes

Health Conditions - Has your child, currently or in the past, been diagnosed with any of the following health conditions:

Asthma*
No
Yes
Diabetes*
No
Yes
Heart Problems*
No
Yes
Vision/Hearing Problems*
No
Yes
Epilepsy/Seizure Disorder*
No
Yes
Frequent Migraine Headaches*
No
Yes
Attention Deficit-Hyperactivity*
No
Yes
Chronic Ear Infections*
No
Yes

If Yes, please explain:

List any other health condition(s) not listed above:

List any medication(s) currently taken by your child:
Fifth Participant's Name

First Name*

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

Emergency Medical Release Form

This form is required for participation in all Impact Bay Area Classes.
Please complete each section thoroughly, sign and date.

Gender:*
Allergies - Does your child have any allergies to food, medications, insects, etc.?*
No
Yes

Health Conditions - Has your child, currently or in the past, been diagnosed with any of the following health conditions:

Asthma*
No
Yes
Diabetes*
No
Yes
Heart Problems*
No
Yes
Vision/Hearing Problems*
No
Yes
Epilepsy/Seizure Disorder*
No
Yes
Frequent Migraine Headaches*
No
Yes
Attention Deficit-Hyperactivity*
No
Yes
Chronic Ear Infections*
No
Yes

If Yes, please explain:

List any other health condition(s) not listed above:

List any medication(s) currently taken by your child:
Sixth Participant's Name

First Name*

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

Emergency Medical Release Form

This form is required for participation in all Impact Bay Area Classes.
Please complete each section thoroughly, sign and date.

Gender:*
Allergies - Does your child have any allergies to food, medications, insects, etc.?*
No
Yes

Health Conditions - Has your child, currently or in the past, been diagnosed with any of the following health conditions:

Asthma*
No
Yes
Diabetes*
No
Yes
Heart Problems*
No
Yes
Vision/Hearing Problems*
No
Yes
Epilepsy/Seizure Disorder*
No
Yes
Frequent Migraine Headaches*
No
Yes
Attention Deficit-Hyperactivity*
No
Yes
Chronic Ear Infections*
No
Yes

If Yes, please explain:

List any other health condition(s) not listed above:

List any medication(s) currently taken by your child:
Seventh Participant's Name

First Name*

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

Emergency Medical Release Form

This form is required for participation in all Impact Bay Area Classes.
Please complete each section thoroughly, sign and date.

Gender:*
Allergies - Does your child have any allergies to food, medications, insects, etc.?*
No
Yes

Health Conditions - Has your child, currently or in the past, been diagnosed with any of the following health conditions:

Asthma*
No
Yes
Diabetes*
No
Yes
Heart Problems*
No
Yes
Vision/Hearing Problems*
No
Yes
Epilepsy/Seizure Disorder*
No
Yes
Frequent Migraine Headaches*
No
Yes
Attention Deficit-Hyperactivity*
No
Yes
Chronic Ear Infections*
No
Yes

If Yes, please explain:

List any other health condition(s) not listed above:

List any medication(s) currently taken by your child:
Eighth Participant's Name

First Name*

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

Emergency Medical Release Form

This form is required for participation in all Impact Bay Area Classes.
Please complete each section thoroughly, sign and date.

Gender:*
Allergies - Does your child have any allergies to food, medications, insects, etc.?*
No
Yes

Health Conditions - Has your child, currently or in the past, been diagnosed with any of the following health conditions:

Asthma*
No
Yes
Diabetes*
No
Yes
Heart Problems*
No
Yes
Vision/Hearing Problems*
No
Yes
Epilepsy/Seizure Disorder*
No
Yes
Frequent Migraine Headaches*
No
Yes
Attention Deficit-Hyperactivity*
No
Yes
Chronic Ear Infections*
No
Yes

If Yes, please explain:

List any other health condition(s) not listed above:

List any medication(s) currently taken by your child:
Ninth Participant's Name

First Name*

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

Emergency Medical Release Form

This form is required for participation in all Impact Bay Area Classes.
Please complete each section thoroughly, sign and date.

Gender:*
Allergies - Does your child have any allergies to food, medications, insects, etc.?*
No
Yes

Health Conditions - Has your child, currently or in the past, been diagnosed with any of the following health conditions:

Asthma*
No
Yes
Diabetes*
No
Yes
Heart Problems*
No
Yes
Vision/Hearing Problems*
No
Yes
Epilepsy/Seizure Disorder*
No
Yes
Frequent Migraine Headaches*
No
Yes
Attention Deficit-Hyperactivity*
No
Yes
Chronic Ear Infections*
No
Yes

If Yes, please explain:

List any other health condition(s) not listed above:

List any medication(s) currently taken by your child:
Tenth Participant's Name

First Name*

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

Emergency Medical Release Form

This form is required for participation in all Impact Bay Area Classes.
Please complete each section thoroughly, sign and date.

Gender:*
Allergies - Does your child have any allergies to food, medications, insects, etc.?*
No
Yes

Health Conditions - Has your child, currently or in the past, been diagnosed with any of the following health conditions:

Asthma*
No
Yes
Diabetes*
No
Yes
Heart Problems*
No
Yes
Vision/Hearing Problems*
No
Yes
Epilepsy/Seizure Disorder*
No
Yes
Frequent Migraine Headaches*
No
Yes
Attention Deficit-Hyperactivity*
No
Yes
Chronic Ear Infections*
No
Yes

If Yes, please explain:

List any other health condition(s) not listed above:

List any medication(s) currently taken by your child:
Parent or Guardian's Email Address

Email*

Confirm Email*
Additional Information

Parent/Legal Guardian Home Phone: *

Work Phone:

Cell Phone # :

Parent/Legal Guardian Home Phone:

Work Phone:

Cell Phone # :

Additional person authorized to pick up my child and/or to contact in case of an illness or an emergency: 


Name:

Relationship:

Phone # :

Name of Child's Physician: *

Physician's Phone # : *

Name of Insurance Company: *

Policy # /Medical #: *
In case of emergency, take my child to the following hospital:
Nearest Hospital

OR


(name of hospital)
  
Upload one of the following: a) photo of minor's CDC vaccination card, or b) screenshot of minor's personal digital COVID-19 vaccine record issued by the State of California and available at myvaccinerecord.cdph.ca.gov. Either document must include minor's name and the date of their final dose.
Valid file types: JPG, GIF, PNG, and PDF
Emergency Release

If, in the judgment of the staff of Impact Bay Area the child named above needs immediate care and treatment as a result of any injury or sickness, I do hereby authorize and consent to any x-ray examination, anesthetic, medical, or surgical or dental diagnosis or treatment and hospital care are considered necessary in the best judgment of the attending physician, surgeon or dentist and performed by or under the supervision of the medical staff of the hospital or facility furnishing medical or dental services. 

I do hereby agree to indemnify and hold harmless Impact Bay Area (including its officers, directors, members and/or volunteers) from any claim by any person whomsoever on account of such care and treatment of said child. It is understood that a good faith attempt shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. Further, it is understood that the undersigned will assume full responsibility for any such action, including payment of costs.

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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Emergency Medical Release Form

This form is required for participation in all Impact Bay Area Classes.
Please complete each section thoroughly, sign and date.

Gender:*
Allergies - Does your child have any allergies to food, medications, insects, etc.?*
No
Yes

Health Conditions - Has your child, currently or in the past, been diagnosed with any of the following health conditions:

Asthma*
No
Yes
Diabetes*
No
Yes
Heart Problems*
No
Yes
Vision/Hearing Problems*
No
Yes
Epilepsy/Seizure Disorder*
No
Yes
Frequent Migraine Headaches*
No
Yes
Attention Deficit-Hyperactivity*
No
Yes
Chronic Ear Infections*
No
Yes

If Yes, please explain:

List any other health condition(s) not listed above:

List any medication(s) currently taken by your child:
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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