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ANTHONY R. FIDEL AND OMULU CAPOEIRA GROUP
COVID-19 Safety Acknowledgment - Liability Waiver and Release of Claims

Read the COVID-19 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 Coronavirus/COVID-19 and 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 Anthony R. Fidel and/or Omulu Capoeira Group.

Coronavirus/COVID-19 SAFETY INFORMATION: While participating in group classes, events, and/or related functions conducted by Anthony R. Fidel and/or Omulu Capoeira Group, “social distancing” must be practiced and face coverings worn at all times to reduce the risks of exposure to Coronavirus/COVID-19. Because Coronavirus/COVID-19 is extremely contagious and is spread mainly from person-to-person contact, Anthony R. Fidel and Omulu Capoeira Group have put in place preventative measures to reduce the spread of Coronavirus/COVID-19. However, Anthony R. Fidel and/or Omulu Capoeira Group cannot guarantee that its participants, volunteers, partners, or others in attendance will not become infected with Coronavirus/COVID-19. In light of the ongoing spread of Coronavirus/COVID-19, individuals who fall within any of the categories below should not engage in group classes, events, and/or related functions conducted in or on rented/reserved/occupied private or public properties and/or indoor/outdoor open spaces conducted by Anthony R. Fidel and/or Omulu Capoeira Group. By attending a group class, event, and/or other related function conducted by Anthony R. Fidel and/or Omulu Capoeira Group at any rented/reserved/occupied private or public properties and/or indoor/outdoor open spaces, you certify that you and/or your child(ren) and/or your guest(s) do not fall into any of the following categories:

1. Individuals who currently or within the past fourteen (14) days have experienced any symptoms associated with Coronavirus/COVID-19, which include fever, cough, and shortness of breath among others;

2. Individuals who have traveled at any point in the past fourteen (14) days either internationally or to a community in the U.S. that has experienced or is experiencing sustained community spread of Coronavirus/COVID-19; or 3. Individuals who believe that they may have been exposed to a confirmed or suspected case of Coronavirus/COVID-19 or have been diagnosed with Coronavirus/COVID-19 and are not yet cleared as non-contagious by state or local public health authorities or the health care team responsible for their treatment.

DUTY TO SELF-MONITOR: Participant(s)/Legal Guardian(s)/Guest(s) agree to monitor/self-monitor for signs and symptoms of Coronavirus/COVID-19 (symptoms typically include fever, cough, and shortness of breath) and, contact Anthony R. Fidel and Omulu Capoeira Group onsite staff immediately if they are experiencing symptoms of Coronavirus/COVID-19 within 14 days after participating event.

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 Anthony R. Fidel and/or 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 ANTHONY R. FIDEL AND HIS FAMILY, 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. 

Coronavirus/COVID-19 has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. 

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

Required to answer.

1. Anthony R. Fidel and Omulu Capoeira Group has put in place preventative measures to reduce the spread of Coronavirus/COVID-19; however, we cannot guarantee that you and/or your child(ren) and/or your guest(s) will not become infected with Coronavirus/COVID-19. Participation includes possible exposure to and illness from infectious diseases including but not limited to Coronavirus/COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist;

2. By signing this agreement, I acknowledge the contagious nature of Coronavirus/COVID-19 and voluntarily assume the risk that I and/or my child(ren) and/or my guest(s) may be exposed to or infected by Coronavirus/COVID-19 by attending group classes, events and/or related functions conducted by Anthony R. Fidel and/or Omulu Capoeira Group and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by Coronavirus/COVID-19 at group classes, events and/or related functions of official and unofficial business or gatherings conducted by Anthony R. Fidel and/or Omulu Capoeira Group may result from the actions, omissions, or negligence of myself and/or my child(ren) and/or my guest(s) and others, including, but not limited to, Anthony R. Fidel and his family, Omulu Capoeira Group, employees, volunteers, and program participants and their families. I knowingly and freely assume all such risks related to illness and infectious diseases, such as Coronavirus/COVID-19, even if arising from the negligence or fault of the Released Parties; and

3. 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 Anthony R. Fidel and/or 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.

4. I acknowledge and agree that it is unequivocally without dispute my responsibility to verbally, and in writing, advise/inform Anthony R. Fidel and 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 Anthony R. Fidel and/or Omulu Capoeira Group.

Today's date: October 26, 2021

First Participant's or Guest's Name

First Name*

Last Name*

Phone*
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

Emergency Contact's 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.
Parent or Legal Guardian's Name

First Name*

Last Name*

Phone*
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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