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Student Information and Release Form

Release Agreement to Assume Risk                                                                                  

As used in the Agreement, the words “I”, “me” and “Participant” mean the person who signs this document. I certify that I am over eighteen (18) years of age and not under legal disability.
In this Agreement, “Instructor” means any staff member at Tiger Rock Martial Arts, its members, managers, partners, shareholders, directors, officers, employees, agents and other representatives, together with all of such persons’ members, managers, partners, shareholders, directors, officers, employees, agents, representatives, legal successors, executors, administrators, personal representatives, heirs, and assigns.
Instructor is engaged in a martial arts business.  Martial arts include many different disciplines and techniques, but all martial arts involve significant risks of physical injury.
Martial arts involve extremely strenuous physical activity, which could cause me to suffer injury or even death from heart attack, stroke, or by exceeding my physical capabilities.
Martial arts also have the risk of injury from physical contact. I understand that there is the ever-present risk of my injury or death, both while I am engaging in martial arts activity and also when others are engaged in martial arts activity. These risks include (but are not limited to) injury to my head, face, eyes and mouth, broken nose, broken bones, spinal and neck injury, injury to internal organs of my body, and injury to soft tissue such as cartilage, tendons, muscle and skin.
I also understand that I may suffer injury because of Instructor’s or Tiger-Rock’s own negligence or because of the surrounding facilities and environment, such as inadequate lighting, Inadequate or missing mats, uneven or unsafe footing, broken or defective equipment, and my use of parking lots, sidewalks, stairs, buildings, and equipment. I understand that Instructor or Tiger-Rock may not have on-site medical personnel, first-aid equipment or supplies.
I have freely and voluntarily chosen to participate in martial arts activity with Instructor, which may include my attendance at events sponsored by Instructor or Tiger Rock (“Events”) and my participation in competitive martial arts (“Competition”). I am not obligated, required or expected to participate in martial arts activity, Events or in Competition. I acknowledge that Instructor and Tiger-Rock will not allow me to participate in martial arts activity or expected in any way to participate in martial arts activity, Events or in Competition, I freely and voluntarily enter into this Agreement.
I am in good physical health and I do not have any disability or other condition which would prevent or limit my participation in strenuous martial arts activity, Events and Competition. I acknowledge that Instructor has advise me (a) to see my doctor before engaging in martial arts activity and (b) to have health insurance coverage.

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Participant'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 information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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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