Child Trial Sign Up

Day of Trial:

Date of Trial:

Name of Student

Date of Birth

If applicable:

Name of Student (2)

Date of Birth

Name of Student (3)

Date of Birth

Preferred Dojo/Venue of Trial

Type of Class

Time of Class

Parent/Guardian Contact Details

Address

Second contact

Further information regarding health or medical issues must be filled out on the back of form.

How did you find out about us?

Name of friend that referred you:

Would you like to recommend a friend to try our free trial offer?

Name of friend

Phone

Email

Medical History

Does your child suffer from any of the following:

Diabetes

Epilepsy

Asthma

Has your child had surgery in the last two years that would affect your exercise

Has your child had an asthma attack requiring immediate medical attention at any time over the last 12 months?

Please list any important medical history, physical or medical limitations or allergies we should be aware of so that we take better care of your child:

Waiver and Release

I hereby WAIVE AND RELEASE TRIFU DOJO (to be known as the “Released Party”) from liability pertaining to the matters set forth below. I understand that by submitting this Waiver and Release, I express and willingly agree to assume complete responsibility for any risk of injury that may arise from the below related activity. On behalf of myself, my child, my heirs, my assigns and next of kin, I waive all claims for damages, injuries and death sustained to me (or my child) or my property that I may have against the above named Release Party relating to such activity. I understand that the activities I or my child will participate in may be dangerous and may cause serious injuries, including bodily injury, damage to personal property and/or death. By this waiver, I assume any risk, and take full responsibility and wave any and all claims of personal injury, including severe bodily injury, damage to personal property and/or death relating to all activities associated with TRIFU DOJO, including but not limited to receiving lessons at the facility, using the facility and it’s equipment, practicing and engaging in Martial Arts activities, and related activities on and off the school premises. If my child is injured from said activity, I will not hold Released Party responsible even if the injuries were caused by negligence on my part or the Released Party, or any other party under or affiliated with the above named Release Party.

I do not have any physical limitations, mental ailments, physical or mental disabilities that would limit or prevent my child from participating in the above-mentioned activity, and, if required, will obtain a medical examination and clearance.

I HAVE READ AND FULLY AGREE TO THE TERMS OF THIS WAIVER AND RELEASE. I UNDERSTAND AND CONFIRM THAT BY SUBMITTING THIS WAIVER AND RELEASE I HAVE GIVEN UP CONSIDERABLE FUTURE LEGAL RIGHTS. I HAVE SIGNED THIS WAIVER FREELY, VOLUNTARILY, UNDER NO DURESS OR THREATS OF DURESS, WITHOUT INDUCEMENT, PROMISE OR GUARANTEE BEING COMMUNICATED TO ME. MY SIGNATURE submission IS PROOF OF MY INTENTION TO EXECUTE A COMPLETE AND UNCONDITIONAL WAIVER AND RELEASE OF ALL LIABILITY TO THE FULL EXTENT OF THE LAW. I AM 18 YEARS OF AGE OR OLDER / LEGAL GUARDIAN AND MENTALLY COMPETENT TO GRANT THIS WAIVER.

By submitting this form you are agreeing to this waiver

Print Name

Date