6_Mom_Kick_Fit_new WOMEN'S KICK-FIT Address: 1455 Youville Drive, Unit 114, Orleans, ON K1C 2X8 Participant Name * Name First Name First Name Last Name Last Name Date of birth * Age Email * Phone number * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Do you have any medical conditions or allergies we should know about? * Yes No If yes, specify * Number of times per week * One day a week for : $60 + hst Two days a week for : $100 + hst Please pick 1 option that work for you * WEDNESDAY : 7:30PM - 8:15PM SATURDAY : 9:00AM - 9:45AM Start date * The First class will start on September 2 Start date. * The First class will start on September 5 Emergency Contact Emergency contact Name * Emergency contact Phone * Payment One day a week Amount HST Total to pay Please process payment to our auto deposit email at orleanstkdacademy@gmail.com for a total of : Payment Two days a week Amount HST Total to pay Please process payment to our auto deposit email at orleanstkdacademy@gmail.com for a total of : Waiver of liability Liability release waiver LIABILITY RELEASE 1. The activities, classes and workshops provided by Orleans Taekwondo Academy . involve risks and dangers of serious health related issues, serious bodily injury, including permanent disability, paralysis and death (the “risks”). There may be other risks either not known to me or not readily foreseeable at this time (the unknown risks”) and I ACCEPT AND ASSUME THE RISKS AND THE UNKNOWN RISKS AND ALL RESPONSIBILITIES FOR ANY LOSSES, COSTS, AND DAMAGES WHATSOEVER that I may suffer and/or incur as a result of attending/participating in any of the Orleans Taekwondo Academy classes, trainings and workshops. 2. That even with clear instructions, there remains possibility of injury and that is my responsibility to consult a physician regarding my ability to participate before coming to Orleans Taekwondo Academy. 3. I attest that I have no physical, psychological, medical or emotional condition that would prevent me from safe participation in any of the Orleans Taekwondo Academy classes and training. 4. I, and my legal representatives, successors and assigns, HEREBY RELEASE AND DISCHARGE Orleans Taekwondo Academy and its administrators, directors, officers, volunteers, instructors, employees and staff, of and from all liabilities, claims, causes of action, losses, and damages in anyway whatsoever arising from or related to my attending/participating in any Orleans Taekwondo Academy classes, trainings or workshops, including but not limited to any claims caused or alleged to be caused in whole or in part by the negligence of Orleans Taekwondo Academy. 5. I, and my legal representatives, successors and assigns, HEREBY RELEASE AND DISCHARGE Orleans Taekwondo Academy and its administrators, directors, officers, volunteers, instructors, employees and staff, of and from all liabilities, claims, causes of action, losses, and damages in anyway whatsoever arising from or related to the loss, theft or damage of any of my personal property from the Orleans Taekwondo Academy premises. 6. I recognize that this agreement of release and waiver of liability is a legally binding agreement and that I understand all the terms provided in this Agreement. 7. I further acknowledge and understand that by signing this agreement, I completely forego all my legal rights to make any claims against Orleans Taekwondo Academy. 8. I further agree in the event that I commence any such claim, action or proceeding, this Agreement may be pleaded by Orleans Taekwondo Academy and its administrators, directors, officers, volunteers, instructors, employees and staff, and by the person, firm or corporation who might have a claim for contribution or indemnity from Orleans Taekwondo Academy as a complete bar and defense to such claim or action, and I agree to indemnify and hold harmless Orleans Taekwondo Academy from any and all claims, causes of action, resulting losses and damages and all expenses and legal fees incurred in responding to the commencement of such claim or action. 9. I understand that my training may involve physical contact, through which I may potentially be exposed to a communicable disease including but not limited to COVID -19. 10. I understand that despite the best efforts of Orleans Taekwondo Academy in maintaining a sanitary working environment, that due to the nature of the virus, I may be exposed to a higher risk of contracting a communicable disease including but not limited to COVID -19 merely by being in a sports facility. I further confirm that I am not currently experiencing, nor have I been diagnosed as suffering from a communicable disease including but not limited to COVID -19 or any of the symptoms of a communicable disease including but not limited to COVID -19, including but not limited to, fever, flu-like symptoms, sore throat, shortness of breath, difficulty breathing, dry cough, loss of taste or smell and/or a runny nose. 11. I understand that I will not be permitted inside Orleans Taekwondo Academy if I am suspected of any communicable disease including but not limited to COVID- 19. I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, AND UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT, ASSURANCE OR UNDUE INFLUENCE OF ANY KIND. I INTEND IT TO BE A COMPLETE AND UNCONDITIONAL ASSUMPTION OF THE RISKS OF THE ACTIVITIES AND A WAIVER AND RELEASE OF THE LIABILITIES OF THE RELEASEES (ORLEANS TAEKWONDO ACADEMY) I AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THAT THE BALANCE IS SEVERABLE AND SHALL CONTINUE IN FULL FORCE AND EFFECT. By signing here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary. Signature * signature keyboard Clear Name of signatory * Date of signature * Captcha Submit If you are human, leave this field blank.
