ADULT RELEASE FORM - ABADÁ-Capoeira San Francisco

2024-2027 Adult Release Form

Pre-Registration is suggested for ALL classes, both online and in-person

Name *

Gender *

I identify my gender as…

Male

Female

Prefer not to disclose

Prefer to describe below...

Address *

Apt, suite, etc.

Country

City

State

Zip code

Phone *

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)

IT 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 Date

2nd

Vaccination Date

Booster

Vaccination Date

Booster

Vaccination Date

Do you have any physical/medical conditions that we should be aware of?

Please specify

Need 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.

Have you ever done Capoeira before? *

If so, with whom? For how long?

Current Cord Level

(if applicable)

Occupation / Hobbies

Release 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.

YES

Participant’s Signature *

(Full name)

Reset Signature

Signature is required.