Hybrid Academy of Martial Arts
5476 Virginia Beach Blvd, Ste. 127
Virginia Beach, VA 23462
www.hybridacademy.com

Full Name:
(First, Last)
Date of Birth:
(Month/Day/Year)
Street Address:
City:
State:
Zip:
Email Address:
Home Phone:
Cell Phone:
Previous Martial Arts Training: (Style and Years of Training)
Personal Training Goals:
Any physical limitations / Medications
Emergency Contact:
Phone Contact:
How did you hear about Hybrid Academy? (Check One)
Television Radio Print Ad Web Site Referral
Referred By:
Other:

Release

It is understood that the class, instructions, and/or lessons, which I have registered for and agreed upon, involve strenuous activity, and may be hazardous, and may result in personal injury. The aforementioned party, whose signature is also hereinafter affixed, hereby waivers and represents that she or he has no knowledge of any physical condition which would render it dangerous and/or hazardous to said party’s health or safety for she/he to participate in such class, instructors, and/or lessons and promises to notify Hybrid Academy of Martial Arts, its agents, and/or instructor(s), should any such condition develop, before the next class which follows discovery and/or awareness by the undersigned of any change in her or his physical condition. Upon receipt of such notification, the instructor(s) reserves the right to terminate and/or discontinue and/or postpone further classes of said individual.

Recognizing, and being fully aware of all the facts, assertions and representations herein before mentioned, the party whose signature is affixed below, (individually) and for his heirs, executors, administrators, successors and/or assigns), expressly assumes all risk of injury resulting directly or indirectly from class, instructors, and/or lessons in the martial arts and associated training received at Hybrid Academy of Martial Arts.

Moreover, in consideration of receiving classes, instructions, and/or lessons at Hybrid Academy of Martial Arts, said party, whose signature is affixed below (individually and for his heirs, executors, administrators, successors and/or assigns), does hereby waive, release, and forever discharge any and all rights and claims for any damages or losses which said party may have, or which may accrue to said party against Hybrid Academy of Martial Arts and/or instructor(s), officers, agents, representatives, successors and/or assigns and against its members for any and all causes which may arise in connection with class, instructions and/or lessons in martial arts and associated training received at Hybrid Academy of Martial Arts.

ALL CONDITIONS ON THIS ENROLLMENT CARD AND RELEASE ENUMERATED ABOVE HAVE BEEN READ, AND FULLY UNDERSTOOD AND ARE ACCEPTED AND AGREED UPON BY THE UNDERSIGNED.

Students will sign a print out in person. Also, students that are under the age of 18 will need to have a parent or guardian to sign the printed copy of this form at the begining of class.