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OMULU CAPOEIRA GROUP

Safety Acknowledgment - Liability Waiver and Release of Claims

Read the Safety Acknowledgement - Liability Waiver and Release of Claims thoroughly. You must provide your initials and sign below acknowledging your assumption of the risk and waiver of liability relating to activity based group classes, events, and all other related functions of official/unofficial business or gatherings conducted by Omulu Capoeira Group (Board of Directors, employees, committee members, instructors, students, contractors, special guests, volunteers, and agents).


LIABILITY WAIVER AND RELEASE OF CLAIMS: I acknowledge that I and/or or my child(ren) and/or my guest(s) derive personal satisfaction and a benefit by virtue of my and/or my child(ren)’s and/or my guest(s)’s participation, and I willingly engage myself and/or my child(ren) and/or my guest(s) in any group classes, events, and/ or any related functions conducted at or on any rented/reserved/occupied private or public properties and/or indoor/outdoor open spaces that Omulu Capoeira Group conducts its official and unofficial business or gatherings.

RELEASE AND WAIVER: I HEREBY RELEASE, WAIVE AND FOREVER DISCHARGE ANY AND ALL LIABILITY, CLAIMS, AND DEMANDS OF WHATEVER KIND OR NATURE AGAINST OMULU CAPOEIRA GROUP AND ITS AFFILIATED PARTNERS AND SPONSORS, INCLUDING IN EACH CASE, WITHOUT LIMITATION, THEIR DIRECTORS, OFFICERS, EMPLOYEES, VOLUNTEERS, AND AGENTS (THE “RELEASED PARTIES”), EITHER IN LAW OR IN EQUITY, TO THE FULLEST EXTENT PERMISSIBLE BY LAW, INCLUDING BUT NOT LIMITED TO DAMAGES OR LOSSES CAUSED BY THE NEGLIGENCE, FAULT OR CONDUCT OF ANY KIND ON THE PART OF THE RELEASED PARTIES, INCLUDING BUT NOT LIMITED TO DEATH, BODILY INJURY, ILLNESS, ECONOMIC LOSS OR OUT OF POCKET EXPENSES, OR LOSS OR DAMAGE TO PROPERTY, WHICH I, MY HEIRS, ASSIGNEES, NEXT OF KIN AND/OR LEGALLY APPOINTED OR DESIGNATED REPRESENTATIVES, MAY HAVE OR WHICH MAY HEREINAFTER ACCRUE ON MY BEHALF, WHICH ARISE OR MAY HEREAFTER ARISE FROM MY AND/OR MY CHILD(REN)'S AND/OR MY GUEST(S)'S PARTICIPATION WITH THE ACTIVITY.

ASSUMPTION OF THE RISK. 

I acknowledge and understand the following: Please acknowledge all two of the following statements by providing your initials to each of the two statements below.

Required to answer.

1. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself and/or my child(ren) and/or my guest(s) (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance at group classes, events and/or related functions of official and unofficial business or gatherings conducted by Omulu Capoeira Group. I hereby knowingly assume the risk of injury, harm and loss associated with the Activity, including any injury, harm and loss caused by the negligence, fault or conduct of any kind on the part of the Released Parties.


2. I acknowledge and agree that it is unequivocally without dispute my responsibility to verbally, and in writing, advise/inform Omulu Capoeira Group of any ongoing or history of preexisting acute and/or chronic medical conditions/medical diagnoses that I and/or my child(ren) and/or my guest(s) present with prior to participation; and/or have incurred a new onset of injury and/or onset of exacerbation related to preexisting acute and/or chronic medical conditions/medical diagnoses during participation in any group classes, events and/or related functions of official and unofficial business or gatherings conducted by Omulu Capoeira Group.


Today's date: November 21, 2024

First Participant's or Guest's Name

First Name*

Last Name*

Phone*
First Participant's or Guest's Age Acknowledgment*
First Participant's or Guest's Date of Birth*
I certify that I am 18 years of age or older
First Participant's or Guest's Signature*
Second Participant's or Guest's Name

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

Last Name*
Tenth Participant's or Guest's Date of Birth*
Participant's or Guest'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 Legal Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Photo/Video release for minors (under the age of 18) who are participant's and/or guest's (Applicable for parent/legal guardian only)
I consent that any photographs, video, digital or film, and other pictures or digital files furnished by me, or obtained of my child in connection with my child's participation in group classes, events or functions in which Anthony R. Fidel and/or Omulu Capoeira Group conducts, or his and/or it's students participate, can be used for publicity, promotion, television, and/or commercial use. I hereby release to Anthony R. Fidel and Omulu Capoeira Group all rights to use such photographs, video, film, and other pictures, and to use my child's name in connection therewith, and I waive any and all compensation in regard thereto.*
No
Yes
N/A
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 Legal Guardian's Name

First Name*

Last Name*

Phone*
Parent or Legal Guardian's Age Acknowledgment*
Parent or Legal Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Legal 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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