Liability Waiver Form "*" indicates required fields PhoneThis field is for validation purposes and should be left unchanged.Application Date:* MM slash DD slash YYYY Email:* Name* First Middle Last Birthdate:* MM slash DD slash YYYY Address* Street Address Apt # City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Age:*U.S. Citizen Yes No If not a citizen are you a Permanent Resident Yes No Birth Country:*Untitled* Male Female Telephone: Home:*Cell*Have you competed professionally in MMA, ultimate fighting, Wildman, toughman or similar competitions Yes No HEALTH AFFIDAVIT ALL BOXERS: I certify that I have had no injuries to my hands, neither fractures nor broken bones, which exist now or occurred within three months proceeding the date of the DNA Level C Boxing Club Membership form, and know of no injuries, to the hand, concussion, fainting spells or headaches. I will notify my coach, trainer, or other Local Boxing Officials immediately should any of these injuries or conditions be experienced in the future. I further agree that if I do experience any of the aforementioned conditions or injuries, I will immediately cease training, sparring and competing as an amateur boxer until such conditions or injuries no longer exists.Signature of ApplicantDate MM slash DD slash YYYY Signature of Parent/Guardian if participant is under 18Date MM slash DD slash YYYY FEMALE BOXERS: I certify that I am not pregnant, or have any painful pelvic discomfort such as endometriosis or other causes, abnormal vaginal bleeding of undetermined causes (Etiology), recent loss of menstrual period, recently developed breast mass, recent breast dysfunction previously not present or surgical breast implants. I further agree that I will immediately notify NNA Level C Boxing Club, my coach, trainer or other Local Boxing Officials if any of the above described conditions should develop and/or apply.Signature of ApplicantDate MM slash DD slash YYYY Signature of Parent/Guardian if participant is under 18Date MM slash DD slash YYYY WAIVER AND RELEASE OF LIABILITY, ASSUMPTION OF RISK & PARENTAL CONSENT & INDEMNITY AGREEMENT IN CONSIDERATION OF ME BEING ALLOWED TO PARTICIPATE IN ANY WAY WITH DNA LEVEL C BOXING CLUB ACTIVITIES, I AGREE I understand the nature of DNA LEVEL C BOXING CLUB activities and my experience and capabilities and believe I am qualified to participate in such activity. I further acknowledge that I am aware the activity will be conducted in facilities open to others during the activity. I further agree and warrant that if I believe conditions to be unsafe, I will immediately discontinue further participation in the activity. I FULLY UNDERSTAND that: (a) DNA LEVEL C BOXING CLUB activities involve risks and dangers of SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS AND DEATH (B) these risks and dangers may be caused by me or the actions or inactions of others participation in the activity, the condition in which the activity takes place. (c) there may be other risks and social and economic losses either known to me or not readily foreseeable at this time, and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES incurred as a result of my participation in these activities. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS the DNA LEVEL C BOXING CLUB, their respective administrators, directors, agents, officers, volunteers, and employees, other participants, any sponsors, advertisers and if applicable, owners and lessors of premises on which the activities take place (each considered one of the "Releases" herein) from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence of the "Releases" or otherwise, including negligent rescue operations and further agree that if, despite this release, I, or anyone on my behalf makes a claim against any of the Releasees named above, I WILL IDEMNIFY, SAVE AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGES OR COST ANY MAY INCUR AS THE RESULT OF SCUH CLAIM. Signature of Applicant:Date MM slash DD slash YYYY CONSENT AND RELEASE OF PARENT OR GUARDIAN I am the parent or guardian of the child applying for membership. My child is fit for participation in DNA LEVEL C BOXING CLUB, activities and I consent to my child's participation. I HAVE READ THE MEMBERSHIP APPLICATION AND WAIVER AND RELEASE. In consideration of allowing my child to participate, I consent to it and agree that IT'S TERMS SHALL LIKEWISE BIND ME, MY CHILD, my heirs, legal representatative, and assignee. I HEREBY RELEASE AND SHALL DEFEN, INDEMNIFY AND HOLD HARMLESS THE RELEASEES FROM EVERY CLAIM AND ANY LIABILITY that I or my child may allege against the Release (including reasonable attorney fees or costs) as a direct or indirect result of injury to me or my child because of my child's participation in the event, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES or other. I PROMISE NOT TO SUE RELEASEES on my behalf of my child regarding any claim arising from my child's participation in DNA LEVEL C BOXING CLUB activities. PARENTS ARE NOT ALLOWED IN THE GYM WHILE THEIR CHILD IS TRAININGSignature of Parent/Guardian if participant is under 18Date MM slash DD slash YYYY Team DNA Boxing may take photos and videos of the child while they are training for marketing purposes.
