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Consultation Form

Student Information

Birthday
Month
Day
Year
Multi-line address

Parent/Guardian Spouse Information

RELEASE AND WAIVER RELIABILITY

I, the undersigned hereby waive all claims against any and all persons associated with the BEEHIVE FIGHT CLUB LLC.. I understand that I am participating in a martial art which has body contact. I understand that this form of martial arts involves choke holds, arm locks, neck cranks, ankle locks, throws, slams, punches, kicks, elbows, knees, and such which could potentially cause serious injury or even death. I assume full responsibility for all my actions during and connected to the above organization. I understand the risk of participating in this form of martial arts training and hereby release the BEEHIVE FIGHT CLUB LLC and all of its agents, employees and associates of and from any and all liability, claims, demands, actions, medical bills, and causes of action whatsoever arising out of or relating to any negligent or other act or omission, and/or any loss, damage, or injury, including death, that may be sustained by the undersigned or any property of the undersigned in participating in this form of training. I, the undersigned also state that I am in good physical condition and know of no reason why I can not train in this form of training. I understand that in case of emergency, I hereby authorize any licensed medical personnel to perform any accepted medical assistance deemed necessary and I agree to bear the expense of any such treatment. As additional consideration for training at BEEHIVE FIGHT CLUB LLC, I agree that my attendance and/or performance at the academy and abroad at events and such may be photographed, filmed and/or taped and used by the BEEHIVE FIGHT CLUB LLC for marketing purposes and I authorize the use of my image and I waive any compensation thereof – even if I discontinue my training at the BEEHIVE FIGHT CLUB LLC. I acknowledge that I would like to receive correspondence from the academy via telephone, mail, and email. I, the undersigned, being duly aware of the risks and hazards inherent upon participating in this form of martial arts agree to all its rules, terms, and conditions. I acknowledge that I fully understand the BEEHIVE FIGHT CLUB LLC rules and sparring rules, have been told of them, understand them, and agree to honor and obey them. I understand that disobeying the rules may, at the instructor’s discretion, result in suspension or expulsion from BEEHIVE FIGHT CLUB LLC and that I will not be entitled to a refund and if expelled must pay the remainder of my contract if one has been signed. In signing the foregoing release, the undersigned hereby acknowledges and represents: that he/she has read the foregoing release, understands it and signs it voluntarily; that he/she is over 18 years of age and of sound mind. If under 18, parent/legal guardian in signing this release agrees to all its terms and conditions.

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11812 Centralia St.
Lakewood, CA 90715
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