Name *
Date of Birth *
Date of Birth
Phone *
(Spouse, Parent, etc)
Emergency Contact Phone *
Emergency Contact Phone
Physical Activity Readiness Questionnaire
Please note that if you answer Yes to any of the questions below that you will not be able to attend a class with Genesis Martial Arts and Fitness Ltd. without further medical or other clearance
Has any doctor ever said that you have a medical condition and that you should only do physical activity that is recommended by a medical professional? *
Have you ever had chest pain when you were and/or were not doing physical activity? *
Do you have any headaches or have you been diagnosed with a concussion in the last 6 months? *
Do you lose your balance due to dizziness or do you ever lose consciousness? *
Do you have bone, joint or any other contagious or non-contagious disease? *
Have you had recent surgery, are you pregnant or have you given birth in the last 6 months? *
Are you taking any legal or illegal substances *
Do you have any objection to provide a criminal record check if we ask you for it? *
(18 years and older)
Waiver and Release *
The “Member” is intending to be legally bound hereby and as a condition of participation at the “GMAF”, expressly agrees to hold harmless and forever release, waive, and discharge the “GMAF”, together with its owners, operators, directors, agents, sponsors, instructors, employees, independent contractors, volunteers and members from any act committed or omitted by him/her, from any and all claims, suits, complaints, liabilities, obligations, demands, actions, or causes of any action whatsoever, that he/she or his/her administrators, executors, heirs, next of kin, or assigns may at any and all times hereafter have or obtain, due to or as a result of, any personal injury, bodily harm or death sustained or suffered by him/her during, or damage to person or property arising out of, or as a result of any “GMAF”, physical or athletic activity, physical instruction or sport conducted or carried on by or for the “GMAF”, whether by itself or with others or in or occurring while he/she is on any premises or property occupied or used by the “GMAF” or at any “GMAF” event, whether caused by active or passive negligence, fault, failure or otherwise howsoever. The "Member" agrees to faithfully comply with all the rules and regulations of the school. The "Member" understands that strict observation of the rules and regulations relative to training include the use of protective equipment required by "GMAF". This equipment will largely eliminate the possibility of accident or injury, however "GMAF" does not warranty the protective equipment. Any photographs or motion pictures taken during participation at "GAMF may be used for promotional purposes. The "Member" also acknowledge the "GMAF" is the sole owner of all pictures and videos recorded on "GMAF" premises and any related events. The "Member" further agrees to release "GMAF" it instructors, representatives and members from any liability for any damage, loss or theft of personal property. The "Member" understands that during the course of instruction, employees of "GMAF" and/or other students or authorized persons will be engaged in a course of conduct requiring physical contact, and the "Member" gives full consent to such contact as is required by the training. The "Member" sings this waiver of liability fully realising that his/her participation or engagement in the activities of "GMAF" may subject him/her to personal injury or bodily harm. The "Member" confirms that engaging in martial arts is a potentially hazardous activity and may result in injuries to him/her for which he/she accepts full responsibility.
Date of Signing *
Date of Signing
Adult Student or Parent/Guardian