If you are human, leave this field blank.2024-2027 Adult Release Form Pre-Registration is suggested for ALL classes, both online and in-personName *Gender *I identify my gender as…MaleFemalePrefer not to disclosePrefer to describe below...Address *Apt, suite, etc.CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabweCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)American SamoaGuamNorthern Mariana IslandsPuerto RicoUS Minor Outlying IslandsUS Virgin IslandsZip codePhone *Email *(Note: Email is the fastest, cheapest way for us to contact you. Please include an active current email. We will not sell or distribute your email or contact info!)Birthdate *(mm/dd/yy)Ethnicity(Optional, but really helpful for us for funding purposes and to help us understand the communities we serve)African-AmericanAsian (specify):BrazilianCaucasianCentral AmericaChineseIndianJapaneseLatino (a)/HispanicMexicanNative AmericanSouth AmericaDecline to stateOther Please specifyIT IS SUGGESTED THAT ALL STAFF AND STUDENTS BE VACCINATED AGAINST COVID-19 Please let us know if you are vaccinated by listing your vaccination dates. 1st Vaccination Date2nd Vaccination DateBoosterVaccination DateBoosterVaccination DateDo you have any physical/medical conditions that we should be aware of?Please specifyNeed Financial Assistance? *No, I can afford a regularly priced class and know my fees support essential operating costs for ACSF.Yes, I am experiencing financial hardship and need low-cost access to classes.Which class(es) are you interested in taking? *Online CapoeiraAll Levels CapoeiraCapoeira BasicsCapoeira Music ClassMaculelêFitness and Other Related ActivitiesHave you ever done Capoeira before? *If so, with whom? For how long?How did you find out about us?Google SearchEventWalked byPublicationFlyerSocial Media or Other (specify)Current Cord Level(if applicable)Occupation / HobbiesRelease and Waive Agreement *I do hereby release (for myself, my executors and administrators) and WAIVE any and all rights to claims for damages arising from any illness, accident or occurrence caused by or as a result of my participation or connection with ABADÁ-Capoeira SF, its instructors, agents, representatives and/or facilities. ABADÁ-Capoeira SF, its agents, instructors, representatives and facilities shall not be held responsible by me for the loss or theft of my or my child’s personal items. I declare that I have read and understood the foregoing statement and that I have either consulted a physician or voluntarily chosen not to consult a physician before, starting or during the course of this program. I have been warned that I must be in good health to participate in this program and I now declare that I am in good health.YESNOParticipant’s Signature *(Full name)Reset SignatureSignature is required.Submit
