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REGISTRATION and WAIVER

PURE SELF DEFENSE

730 W. INDIANTOWN ROAD

JUPITER, FLORIDA 33458

Registration Information

WAIVER AND RELEASE OF LIABILITY AGREEMENT

READ CAREFULLY BEFORE SIGNING — THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS

IF YOU ARE A GUARDIAN, YOU MUST FILL OUT THE ENTIRE REGISTRATION FORM YOURSELF.

1. Assumption of Risk

I UNDERSTAND THAT PARTICIPATION IN MARTIAL ARTS, SELF-DEFENSE, FITNESS TRAINING, OR COMBAT SPORTS INVOLVES INHERENT RISKS OF PHYSICAL INJURY, INCLUDING SERIOUS INJURY, PERMANENT DISABILITY, PARALYSIS, OR DEATH. These activities involve vigorous physical exertion, potential physical contact with others, and the use of training equipment that may cause injury. I VOLUNTARILY ASSUME ALL RISKS ASSOCIATED WITH PARTICIPATION, WHETHER FORESEEABLE OR NOT, INCLUDING THOSE ARISING FROM NEGLIGENCE BY PURE SELF DEFENSE, ITS OWNERS, STAFF, INSTRUCTORS, COACHES, AFFILIATES, GUEST BLACK BELTS, SEMINAR PRESENTERS, INCLUDING DR. GAETANO SCUDERI.

I acknowledge that my participation is entirely voluntary and that I am not under any obligation or coercion to engage in these activities. 



2. Release and Waiver of Liability

IN CONSIDERATION FOR BEING ALLOWED TO PARTICIPATE, I HEREBY RELEASE, WAIVE, DISCHARGE, AND HOLD HARMLESS PURE SELF DEFENSE; ITS OWNERS; EMPLOYEES; INSTRUCTORS; COACHES; AFFILIATES; VOLUNTEERS; SEMINAR PRESENTERS; VISITING BLACK BELTS; AND SPECIFICALLY DR. GAETANO SCUDERI (HEREAFTER COLLECTIVELY “RELEASEES”) FROM ANY AND ALL LIABILITY, CLAIMS, DEMANDS, OR CAUSES OF ACTION WHATSOEVER, INCLUDING BUT NOT LIMITED TO THOSE ARISING FROM THE NEGLIGENCE OF RELEASEES.

This release includes, without limitation, injury, illness (including infectious diseases), or damage to personal property, whether sustained during classes, seminars, workshops, open mats, competitions, demonstrations, or any related activities on or off premises. 

I Agree

3. Indemnification

I agree to DEFEND, INDEMNIFY, AND HOLD HARMLESS the Releasees against any claims, lawsuits, damages, costs, or attorney’s fees arising out of my participation or conduct while engaging in any activities under the auspices of PURE Self Defense. 

I Agree


4. Medical Authorization

I represent that I am in good physical condition and understand that it is my responsibility to consult a physician before beginning training. In the event of injury, I authorize PURE Self Defense staff to obtain emergency medical treatment on my behalf. I acknowledge that I am solely responsible for all associated medical costs and that PURE Self Defense does not provide health insurance or medical coverage. 

I Agree


5. Photo/Video Consent

I grant PURE Self Defense permission to take photographs or video recordings of me for marketing, promotional, or instructional purposes without compensation and waive any rights of publicity or ownership.

I Agree


6. Governing Law and Venue

This Agreement shall be governed by the laws of the State of Florida, and any legal action shall be brought exclusively in a court of competent jurisdiction in Palm Beach County, Florida. If any provision of this Agreement is held to be invalid or unenforceable, that provision shall be severed and the remainder of the Agreement shall remain in full force and effect to the fullest extent permitted by law.

I Agree


7. Medical Release

I acknowledge that some of the instructors that teach/instruct, assist at Jupiter selfdefense/Scuderi self-defense may be physicians or other healthcare providers and any and all communication, discussions, advice, or correspondence of any sort regarding any potential or current medical condition is not to be construed or understood in anyway as initiating or continuing a doctor patient relationship. Any and all advice given is not considered medical advice from physician to patient/student. I voluntarily certify that I will not hold Pure Self Defense/Scuderi self-defense/Gaetano J Scuderi MD and any of their agents/assignor’s/staff/instructors responsible for any injury whether as a result of training or not or statements regarding any possible medical discussions.

I Agree


I further agreed to pay a registration fee of $45 and the monthly tuition on the first of each month and agreed to give 30 DAYS NOTICE OF CANCELLATION if I wish to discontinue the program. Otherwise, I understand fully that cancellation will be processed the following month if the 30 days written notice is not given. (Yearly commitments must be fulfilled entirely, if cancelled before term is up I agree to pay the early cancellation fee) BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ THIS AGREEMENT, UNDERSTAND IT, AND VOLUNTARILY AGREE TO ITS TERMS, INCLUDING THE RELEASE OF LIABILITY FOR NEGLIGENCE.

 

April 1, 2026

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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.
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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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