Pilates Studio | Flow State Pilates

First Name / Child's First Name

Last Name / Child's Last Name

Date of Birth DD/MM/YY

Phone Number

Emergency Contact Name

Emergency Contact Number

Do you (or your child) have any physical or mental health conditions, illnesses or injuries or take any medication that Flow State should be aware of prior to you starting Jiu-Jitsu?

Yes

If yes - please provide relevant details

To ensure the safety and wellbeing of everyone, Flow State may determine whether participation is appropriate where there are safety concerns.

I have been briefed on the risks involved.

I accept that these activities are dangerous and can result in serious injury including death.

I accept the risks involved and I am responsible for my own (or childs) actions and/or involvement.

To the best of my knowledge I have answered the questions above truthfully. I understand and agree that it is my responsibility to inform Flow State Jiu-Jitsu of any conditions or changes in my / my child's health, now and on-going, which might affect my / my child's ability to participate safely in required exercises.

DECLARATION

The following declaration is to be made by the participant if aged 18 years or over, or by their parent or legal guardian if the participant is under 18 years of age.

I hereby declare that the above particulars are true and correct.

I acknowledge that during such times as I am on the premises or participating in any activity external to the premises which is organised, approved or endorsed by Flow State Jiu-Jitsu as an activity for me to take part in, both my property and my person shall be at my own risk in every respect and hereby disclaim and release Flow State Jiu-Jitsu and every occupier thereof, all employees, agents, independent contractors, voluntary workers from any liability for any personal injury or loss of property.

I declare that I am in good health and physically able to participate in classes at Flow State Jiu-Jitsu.

I will inform instructors of any condition that may affect my ability to participate in any class, prior to that participation.

I have read, understood and agree to the terms above

Signature

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