2022 Valor Cup Registration is Open!

Family Dr. Name *

Family Dr. Phone *

Insurance Name

Emergency contact person name

Emergency Contact Phone

Allergy

Waivor *

Please read this form carefully and be aware in participating in the Valor Cup provided by Agape Black Belt Center, that you will be waiving and releasing all claims for injuries you might sustain, arising out of this participation. I recognized and acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any injuries, including death, damages, or loss which I may sustain as a result of participating in any and all activities and events connected with or associated with such program. I agree to waive and relinquish all claims that I may have as a result of participation against Agape Black Belt Center, their officials, agents, instructors, employees, and volunteers. I do hereby fully release and discharge, Agape Balck Belt Center their officials, agents, instructors, employees, and volunteers from any and all claims from injuries, including death, damage, or loss which may accrue on account of participation. I further agree to indemnify and hold harmless and defend Agape Black Belt Center their officials, agents, instructors, employees, and volunteers from any and all claims resulting from injuries, including death, damages, and losses sustained by me or arising out of, connected with, or any way associated with the activities of the event.Yes. I agree

Name *

Student Information

Student Contact

Rank

Event

Emergency Information

Weight & Hight

Verification