Participants Name (First and Last)
* Home Address
Emergency Contact Person
Emergency Contact Phone Number
* Emergency Contact Phone Number
Before you take your first class, we ask that you complete some brief health information, so that we can know if you have any special needs. If you are over 69 years of age and/or you are not used to being active, check with your doctor.
If you answered YES to one or more questions, you should consult your doctor before becoming more physically active.
If you answered yes, please explain.
WAIVER/RELEASE OF LIABILITY
In consideration of your acceptance of this form, I for myself, my heirs, executors, administrators and assigns, forever waive, release and discharge any and all rights, claims for damages, unknown, that I may have against ONE WITH HEART, their employees, members, or instructors, for any and all injuries in any manner arising or resulting from my participation in classes. I attest and verify that I have full knowledge of the risks involved in any martial arts, weights, exercise, and fitness programs and that I freely and voluntarily assume those risks as incident to participation, and that I will assume and pay my own medical and emergency expenses in the event of accident, illness, or other incapacity, regardless of whether I have authorized such expenses, and that I am medically and physically fit and able to participate in classes. I also give consent to ONE WITH HEART, its owner, teachers, employees, and other students to give minor emergency first aid and/or advice to me. I hereby release claims I have towards them for giving me such treatment. All dues and payments for classes are nonrefundable and non-transferable. One With Heart has the right to cancel classes and workshops due to inclement weather for the safety of One With Hearts members. Refunds will be given for workshops but no prorates for on-going classes. I give ONE WITH HEART permission to use any photos/videos taken of me for publicity.
Parent or Legal Guardian Signature (If under 18 years old)
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Select Session for Intro
Pick either morning or evening sessions. If you pick morning sessions and happen to miss one of your classes, you may make it up in the following evening class and vice versa.
Step 1 - Complete — Thank you! Step 2 - Pay for Adult Pukulan Intro