Gracie Barra North Austin Trial Form

Student Information

Full Name *

Phone *

Date of birth

Email *

Student Weight

Student Height

Allergies and Medical Conditions (put 0 if none) *

Emergency Contact (Name) *

Emergency Contact Number *

Please specify who referred you (if this is a person)

RELEASE

I hereby acknowledge and understand that this Seminar involves physical activity and learning self-defense skills involves physical contact. Gracie Barra North Austin and its staff and students are not to be held liable or responsible for any risks and/or injuries as a result of participating. The people stated above hereby hold Gracie Barra North Austin, its successors, assigns, owners, officers, directors, employees, and agents harmless from all claims which may be brought against them by the people stated in this contract, student or on student's behalf for any such injuries or claims and do hereby forever release and discharge Gracie Barra North Austin, its successors, assigns, owners, officers, directors, employees, and agents from all claims, demands, injuries, damages, actions, losses and expenses. *PARENT/ GUARDIAN CONSENT: The below said person is the legal parent or guardian of the student participating in this class. The below person consents to the student participating in the classes/training and are aware of the risks involved in such participation. PHOTO RELEASE: I hereby grant Gracie Barra North Austin permission to use my likeness in photographs, videos, or other digital media (“photos” or “pictures”) in any and all of its publications, including web-based publications, without payment or other consideration.

Signature *

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FOR MINORS ONLY - Parent/Guardian Information (IF PARTICIPANT IS UNDER 18 YEARS OF AGE)

Relationship to student

Phone number of guardian/parent

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