Welcome to the Academy!   Please fill out and sign the form completely.

Event: ______________________________       Date: __/__/__       Start Time: _______

Name: ___________________________________________    DOB: ____/____/____

Address: ____________________________________  City:______________________ 

State: ___________________  Zip:________  Ph #:_____________________________

Email: _________________________________________________________________ 

Medical Conditions or Medications:  __________________________________________

Guest of: _________________________________________   (AMA Student’s Name, if applicable)

RELEASE AND WAIVER OF LIABILITY

In consideration of services to be received on these premises, the undersigned hereby releases and forever discharges the school, its heirs, successors, administrators and assigns from any and all actions, cause of actions, liability, claims and demands upon or by reason of any damage, loss, injury or suffering known and unknown which may be sustained by the student named above in connection with and in the course of receiving training from the instructor or instructors, staff, officials, assistants, or employees of this school or any fellow students at this school in connection herewith and within the course of taking training or lessons for the purpose designed in this application.  He/she hereby waives all his/her rights to the claims, actions, cause of action, demand or suit for loss, injury, damage, or suffering sustained as a result of anything other than gross negligence on the part of this school.  The undersigned assumes all the risks inherent and incident to this type of activity as a condition for applying for admission to this school for the purpose hereinabove stipulated.

As with all physical activities, I understand that I should check with my doctor before beginning any new exercise program.

Media release: We retain the right to use names, photos and videos taken during school activities for publicity purposes.

________________________________________           __________________________________________

Signature of Guest                                   Date                   Staff                 Date

________________________________________ 

Parent or Guardian if under 18                   Date