Liability AgreementName(Required) First Last Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Phone(Required)Occupation(Required)Have you ever been involved in:(Required) Boxing Kickboxing MMA NoWhere did you practice the above activity(ies)?(Required)What type of results are you trying to obtain?(Required) Stamina Strength Self Confidence Weight Loss OtherHow long has it been since you have been in your ideal shape?(Required)How long have you been thinking about starting a boxing or kickboxing program?(Required)Are there any physical or emotional conditions that would hinder you from participating in a boxing or kickboxing program?(Required) Yes NoExplain the above conditions:(Required)What has kept you from starting in the past?(Required) Time Money Facilities ProcrastinationDo you plan to stay in the area?(Required) Yes NoGUEST ASSUMPTION AND RELEASE OF LIABILITY(Required) I agree to these termsBoxing and kickboxing courses offered by Bay Area Boxing of Belmont, CA and its owners, employees, instructors (collectively “Fitness Center”) will involve sparring and physical contact with other individuals and/or heavy bags, which may result in personal injury. Other programs offered by the fitness center, including weight lifting, martial arts, aerobics’, wrestling, cycling, and other events also present a risk of personal injury to the participant (yourself). By signing below, I am acknowledging my intent to release, waive, and discharge the Fitness Center from any claim or liability for injury to my person, my children, or other minor persons for whom I am responsible, hereafter occurring at or around the Fitness Center. Accordingly, I, for myself and my children, and for my or their successors, personal representatives, and assigns hereby (1) release and waive any claims and causes of action against the Fitness Center for personal injury, loss and/or consequential damage to me, my children, or other persons for whom I am responsible, resulting from future passive or active negligence of the Fitness Center in operation, management or supervision of the Fitness Center, and (2) agree to indemnify, defend and hold the Fitness Center free and harmless from any cost, loss or liability arising out of any injury to me, my children, or other persons for whom I am responsible in or around the Fitness Center proximity resulting from negligence of the Fitness Center.Today's Date(Required) MM slash DD slash YYYY Your Signature(Required)By signing this field you agree to the above TERMS.Δ
