Name * First Name Last Name Guest's age * If more than one guest please add additional name(s) and age(s) in the MESSAGE area toward the bottom of this form. Attending parent / legal guardian name (if applicable) First Name Last Name Cell phone * (###) ### #### Email * How'd you hear about LEVEL 3? * Poster / Flyer Doorhanger Drive / walk by Google internet / maps search Yelp Facebook / Instagram NextDoor Online other Referred Advertisement Community event Auction / fundraiser Gift certificate Other Program(s) of interest * Jiu-Jitsu Kempo Martial Art & Self-Defense Women's Self-Defense Junior Martial Athletes (ages 11 - 14) Champion Children (ages 7 - 10) Tiny Tigers (ages 5 & 6) Little Leopards (ages 3 & 4) Your goals (check all that apply) Self-defense Competition Physical conditioning (endurance, strength, flexibility...) Stress relief Focus & discipline Academic improvement Sleep improvement Achieve Black Belt Lifestyle / new hobby Please write the name(s) and age(s) of additional guests that are participating in this visit Referring student's name (if applicable) First Name Last Name Scheduled class date * MM DD YYYY If you have any previous injuries or concerns please describe here. If none, write "NONE". * Waiver / liability release * By checking here, I, the applicant, on behalf or myself, family members, heirs, executors, and other persons of which I am related or connected to in a personal and/or professional manner, hereby release and hold harmless LEVEL 3 Martial Arts Performance (L3MAP), the instructors, all participants, and any related entities, for any injury or loss to my person or property arising out of or in connection with my participation or martial arts fitness and self defense training, speciality events, or other activities in a public, group, and/or private instructional format, notwithstanding that the same may have been contributed to or occasioned by the negligence of L3MAP or others. I realize I am responsible for my own safety and the safety of others around me. If injury occurs, I agree to immediately report the injury to the instructor so that if necessary, L3MAP and/or related representatives shall be authorized to obtain medical treatment as may be necessary and appropriate in emergency circumstances. I also agree I will train safely and respectfully without malice and that intentionally harming another person during my training may be punishable to the fullest extent of the law and that remedies may be sought. I confirm that I am healthy with no contractable illnesses or disease and have not been knowingly exposed to anyone recently with a contractible illness. I agree to follow all safety policies and etiquette while engaging in all L3MAP activities. I/WE are choosing at our own risk to participate in an activity considered "higher-risk" during the ongoing pandemic and accept all responsibility for any injuries, sickness, damages, or death to myself or my family that may occur as a result of said participation. If my actions during my visit cause damages to the L3MAP operation, brand, its instructors, or its members I accept full responsibility for all remedies that may be sought. I agree Responsible party name * By entering your full name here you agree you are the responsible party age 18+ and are permitted to agree to the above waiver and that the information you provided is true and correct: First Name Last Name Message * IN-PERSON ONLY (when required): Legal guardian / guest signature We look forward to training with you!
