MASG LIABILITY RELEASE Client Information Name ____________________________________________________________ D.O.B ______________________ Address ________________________________________________________ Phone #1 ______________________ City ____________________________________________ Zip ___________ Phone #2 ______________________ Occupation ___________________________________________ Email ___________________________________ Emergency Contact ______________________________________________________________________________ Phone __________________________________________ Relationship ___________________________________
Rules and Regulations of participation: All participating individuals (hereafter to be referred to as P.I.) are required to cause no harm to himself or herself or another P.I. of the martial arts study group. Medical Release: In the event of an emergency, the P.I. hereby authorizes transportation and licensed personnel to perform any accepted medical procedures on the P.I. deemed necessary or advisable, and agrees to bear the expense of any such transportation or procedures (Initial ________).
Release of Liability: Martial arts instruction will involve physical contact with other individuals, which may result in accidental personal injury. By signing below, I am acknowledging my intent to release, waive, and discharge Kurt Deutschbein from any claim or liability for injury to P.I. occurring during their personal study with Kurt Deutschbein. This includes injury from any cause, whether or not such injury results from the active or passive negligence of Kurt Deutschbein. I, for myself and my children, and for me and my childrenâ€™s successors, our personal representatives, and assigns, hereby release and waive any claims and causes of action against Kurt Deutschbein for personal injury, loss and/or consequential damage to me or my children resulting from the future passive or active negligence of Kurt Deutschbein in our study of the martial arts. I agree to indemnify, defend and hold Kurt Deutschbein free and harmless from any cost, loss, or liability arising out of any injury to myself or my children, in or around Kurt Deutschbein while participating in the study of martial arts.
Client (P.I.):(print please): _________________________________________________ Date: _________________
Client (or P.I. guardian): ________________________________________________________________(signature)
Witness: _________________________________________________________________ Date:_________________