Poomsae Workshop Registration - NON MEMBER

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 Poomsae workshop 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 the Agape Black Belt Center its officials, agents, instructors, employees, and volunteers. I do hereby fully release and discharge Agape Black Belt Center and their officials, agents, instructors, employees, and volunteers from any and all claims from injuries, including death, damage, or loss that 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 *

Poomsae Workshop Registration - NON MEMBER

Student Information

Student Contact

Workshop

Emergency Information

School & Rank

Verification

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