MMA Barn
(Holy Zion Church of the Jubilee)
465 Park Ave., Windsor Ct. 06095
(ph) 860-655-2269
Welcome to MMA BARN
Student Registration
{name}
{address}
{phone}
{sign_date}SEX M F AGE
{dob}EMPLOYED BY{email}
PRE-EXISTING CONDITIONS/INJURIES:
DOCTOR PHONE
INSURANCE CO POLICY #
IN CASE OF EMERGENCY NOTIFY {contact_name} PHONE {contact_phone}
General Waiver
MMA BARN
PLEASE NOTE: This waiver of Liability, Release, Acknowledgement of Risk, and Indemnification
Agreement (“Waiver Agreement”) is intended to be, and is, legally binding.
If any aspect of this Waiver Agreement requires clarification, have a MMA BARN,
employee fully explain it before signing. By signing the MMA BARN “Student Registration” you
are agreeing to all terms set forth in this Waiver Agreement. You and/or the person on
whose behalf you are signing, are waiving the right to bring any type of action, whether in
court or otherwise, to recover compensation or obtain any other remedy for any personal
injuries, damages to property, any accident or incident of any type, or death, arising out of
or related to your use of MMA BARN, its facilities, grounds, climbing walls, exercise areas,
classes, equipment, whether the use is supervised or unsupervised. While Brand MMA
BARN offers these activities in a controlled environment, there is still an assumed risk of
injury to persons using MMA BARN. In agreeing to this Waiver Agreement, I hereby
acknowledge, understand, and agree on my behalf, and upon behalf of the person for whom I
am signing, that the use of MMA BARN, its facilities, equipment, climbing walls, classes and/or
participating in activities sponsored by MMA BARN have inherent risks. These risks include, but
are not limited to, any injury of damage resulting from:
Negligence of employees, volunteer assistants, independent contractors of MMA
BARN. Negligent misuse of the facility, climbing walls, or equipment of MMA BARN;
falling off or impacting against the climbing walls, impact surface, floors, or anything else;
rope abrasion, entanglement or other activities occurring on the premises; cuts or abrasions
resulting from any cause whatsoever; failure of the climbing walls or equipment,
whether inside or outside; personal health problems, whether mental or physical; negligence
of other climbers, visitors, or observers or persons who may be present in or around the
climbing area or facility; and/or negligence or lack of adequate training of any person(s) who
seek to assist with medical or other help either before or after any injury or damage may occur.
Initials
MMA BARN AGREEMENT AND RELEASE OF LIABILITY
1. In consideration of being allowed to participate in the activities and programs of MMA
BARN and to use its facilities, equipment and machinery in addition to the payment
of any fee or charge, I, for myself, my heirs and assigns, hereby waive, release, and
forever discharge MMA BARN, and their officers, agents, employees, representatives,
executors and all others from any and all, responsibilities or liability from injuries or
damages resulting from my participation in any activities or my use of equipment,
classes, climbing walls or machinery in the above mentioned activities. I do hereby
release all of those mentioned and any others acting upon their behalf from any
responsibility or liability for any injury or damage to myself, including those caused by
the negligent act or omission of any of those mentioned or others acting on their behalf
or in any way arising out of or connected with my participation in any activities of MMA
BARN or the use of any equipment at MMA BARN.
2. I understand and am aware that, fitness, and climbing including the use of the equipment,
are all potentially hazardous activities. I also understand that fitness activities involve a
risk of injury or even death, and that I am voluntarily participating in these activities and
using equipment and machinery with knowledge of the dangers involved. I hereby to
expressly assume and accept any and all risks of injury or death.
3. I do hereby declare myself to be physically sound and suffering from no condition,
impairment, disease, infirmity, or other illness that would prevent my participation or
use of equipment, climbing wall or machinery except as herein stated. I acknowledge
that I have either had a physical examination and been given my physician’s permission
to participate, or that I have decided to participate, in the activity of, fitness, and climbing
and the use of the equipment, climbing wall and machinery without the approval of my
physician and do hereby assume all responsibility for my participation and activities, and
utilization of equipment and machinery in my activities.
{sign_date}
Parent and/or Guardian must sign below for minors
AGREEMENT AND RELEASE OF LIABILITY
In consideration of having MMA BARN allow my child, , who is under the age of 18 to participate in the activities and programs of MMA BARN, including but not limited to MMA BARN, Climbing and use of the climbing wall and any other equipment, I hereby for my child’s heirs, executors, administrators, and or assigns, waive and release any and all rights and claims of any nature my child may have against MMA BARN, its officers, employees, agents, chapters, assignees,
licensees, and cooperating entities, their representatives, heirs, executors, administrators, successors, and assigns for and against any and all injuries or damages of any nature my child may suffer while taking part in any activities connected with MMA BARN. This release and consent shall be binding upon my child’s heirs, executors, administrators, and/or assigns.
{sign_date}
Photo / Video R el ease
I hereby give permission for images of my child, captured during regular and special
activities through video, camera and digital camera to be used solely for the purposes of
MMA BARN promotional material, publications and web site,and waive any rights of
compensation or ownership thereto. Last names of minors will not be given or posted on the
web site.
Name of minor Name of Parent/Guardian {sign_date}
Initial :
Initial :
