Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone Number *Enter your phone numberEmail * I hereby acknowledge and agree to the following, as a condition of a Seniors Fight Back Seminar. *FirstLastPlease read and check ALL:1) My involvement and/or participation in this Self Defense Seminar is voluntary, and I/or/my child, is acting under myself/or/my permission, and own free will.2) I understand that there is a risk of danger, bodily harm, injury, emotional stress or death as a result of my/or/my child’s participation. The risks arising from Self Defense training/sparing/striking/being struck, that can cause the risk, with acknowledgement that potential risks are not limited to this list.3) There is a potential for risks and dangers that may not be obvious or reasonably foreseeable at this time.4) I/or/my child do/does not have any medical ailments, physical limitations, or mental disabilities that will affect my/or/my child’s ability to participate in Self Defense.5) I understand this Self Defense Seminar has been designed to provide me/or/my child with the safest and most effective way to survive and escape a physical assault. However, I understand that the instructors cannot guarantee my safety through the use, or misuse, of the techniques taught in this Self Defense Seminar.6) Seniors Fight Back, the venue and/or the Instructor in charge undertakes no direct legal or financial responsibility for my/or/my child’s personal safety or well-being when I/or/my child is participating in this Self Defense Seminar.7) I assume the risks, including but not limited to those outlined above in sections 1 through 5 of this agreement.8) I forever release Seniors Fight Back, the venue, and it’s Instructors and all related participants, from any and all claims and causes of action that I/or/my child’s representatives now or may have in the future for personal injury, property damage or wrongful death occurring to me/or/my child, arising out of participation in this Self Defense Seminar.9) I am 100% liable for all medical expenses incurred as a result of any injury or property damage during my/or/my child’s participation in this Self Defense Seminar.10) In the event that any one or more of the provisions of this agreement shall be held to be invalid, illegal, and enforceable or in conflict with the law according to the jurisdiction, of the state of California, the remaining portions will not be invalidated, and shall remain in full force and effect.11) This is a legally binding contract, but it is not meant to pronounce any claims or defenses that are legally prohibited.I attest that I have read and understand this document, and agree to all provisions listed above.Participant Signature *Date: *Parent/Guardian Signature (if applicable)Date: *Submit
