Welcome
Beginners Series
Contact
Learn
Search
Gear
Capoeira Gear
Kids Capoeira Gear
Classes
Schedule
Locations
Kids
How much is it?
Welcome
Beginners Series
Contact
Learn
Search
Gear
Capoeira Gear
Kids Capoeira Gear
Classes
Schedule
Locations
Kids
How much is it?
UCAinLA Online Waiver
UCAinLA Online Waiver
Date
*
MM
DD
YYYY
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Birthdate
*
MM
DD
YYYY
Phone
*
(###)
###
####
Work Phone
(###)
###
####
Email Address
*
Occupation
*
Understanding what you do for a living is extremely important when considering how to specifically tailor capoeira class for you.
How did you find out about us?
*
Please share how you found out about us.
Online Search
facebook
twitter
yelp!
UCAinLA student referral
I saw a live demonstraiton
A Capoeira school
Friend
Flyer
Other
Have you seen Capoeira before?
*
Yes
No
If you answered yes
*
Please tell us where you have seen capoeira before.
Live Demonstration
Performance
Brazil
YouTube
A Capoeira school
Why do you want to learn Capoeira?
Please tell us a little about your interest in the art.
PERSONAL MEDICAL INFORMATION
(NOTE: ALL OF THE INFORMATION IN THIS SECTION WILL BE TREATED AS STRICTLY CONFIDENTIAL, AND WILL BE USED ONLY IN THE DETERMINATION OF THE APPLICANT'S FITNESS TO PARTICIPATE IN MARTIAL ARTS ACTIVITIES WITH UNITED CAPOEIRA ASSOCIATION LOS ANGELES AND IN CASE OF EMERGENCY.)
Are you allergic to any medications?
*
Yes
No
If you answered yes, please explain:
Any medical conditions we should be aware of
*
For example: recent surgery, diabetes, contact lenses, etc.
Yes
No
If you answered yes, please explain:
Any medical/physical conditions that may affect you or your ability to participate in class?
*
for example, knee or back problems, neck injury
Yes
No
If you answered yes, please explain:
Name of Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
(###)
###
####
Relationship to you
*
AGREEMENT, ASSUMPTION OF RISKS, AND WAIVER OF LIABILITY
After discussing with Michael G. Davis, Instructor, I wish to become a student of capoeira with the United Capoeira Association Los Angeles (“UCALA”) and understand the nature and type of instruction that UCALA provides to its members. I hereby certify that I have read and agreed to each of the following provisions and agree to be bound by the terms herein:
1. I understand that capoeira, and such other martial arts as instructors and I include in my studies are martial arts; that is, systems of unarmed and armed fighting techniques that may include personal body contact.
2. I understand that these martial arts will require me to engage in strenuous physical exercise and activity, either individually or in participation in class with other students or instructors at UCALA facilities or elsewhere, and that the martial arts techniques which I learn at UCALA are capable of causing minor or serious physical injury (including abrasions, bruises, bleeding, broken bones or cartilage, or other tissue or organ damage), emotional or psychological injury, death, or property damage, whenever I use them against another person or physical objects, either in class at UCALA facilities or elsewhere.
3. I understand that my participation in class at UCALA will require me to engage in conditioning exercises, formal exercises, and other physical activities that involve a risk that I will be subject to minor or serious physical injury (including abrasions, bruises, bleeding, broken bones or cartilage, or other tissue or organ damage), emotional or psychological injury, or death as a result of these exercises and activities.
4. I understand that the types of injuries described in paragraphs 2 and 3 may result not only from intentional action, but also from inadvertent, negligent, or reckless action, by myself or others, including the malfunction or failure of any of the equipment or facilities at UCALA facilities or elsewhere (including pads, protectors, punching bags, and tumbling mats) and errors or mistakes in instruction or performance of fighting or defense techniques by instructors or other students at UCALA.
5. I understand that the risks of any and all of the types of injuries described in paragraphs 2-4 cannot be significantly reduced or eliminated without adversely affecting, and even jeopardizing, the nature and quality of the instruction and activities at UCALA.
6. I understand that neither UCALA nor any of its owners, operators, officers, employees, instructors, students, or agents authorize me to use any of the fighting or defense techniques that I learn in my studies at UCALA against any other person, in any circumstances other than (a) martial arts training, matches, exhibitions, or demonstrations in which my instructors and I agree I am sufficiently qualified and physically able to participate at UCALA or elsewhere, and (b) self-defense or defense of others in a situation that involves the risk of imminent physical injury or death.
7. In the light of all of the foregoing understandings, I knowingly and voluntarily agree to assume all of the risks associated with participation in classes at UCALA facilities or elsewhere, including those risks described in paragraphs 2-4, and knowingly and voluntarily hold harmless, and waive any and all rights to initiate or maintain a lawsuit or otherwise seek or obtain any finding of liability against, UCALA and any of their owners, operators, officers, employees, instructors, students, or agents and I assume the risk of all injury to myself and to my personal belongings.
8. I intend this Agreement, Assumption of Risks, and Waiver to be binding upon any and all of my parents, children, present and former spouses or life partners, heirs, assigns, friends, personal representatives, and estate in perpetuity.
9. I also understand that at no time am I authorized to teach capoeira until I have graduated from the capoeira school.
Applicants Name
*
First Name
Last Name
Today's Date
*
MM
DD
YYYY
YOUR AGREEMENT WITH THE ASSUMPTION OF RISKS AND WAIVER OF LIABILITY
I hereby certify that I have read and agreed to each of the following provisions and agree to be bound by the terms described above.
Did you read the terms and conditions carefully?
*
Your agreement to these terms and conditions is required in order to participate in capoeira classes with Michael G Davis, Instrutor Guatambu, and the United Capoeira Association Los Angeles.
Yes
If Applicant Is A Minor At Time of Application:
PARENT/GUARDIAN AGREEMENT WITH ASSUMPTION OF RISKS AND WAIVER OF LIABILITY
Parent or Guardian Name
First Name
Last Name
Date
MM
DD
YYYY
Address of Parent or Guardian
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
As the Parent or Guardian of:
Child's Name
First Name
Last Name
I hereby certify that I have read and agreed to each of the following provisions and agree to be bound by the terms described above
Yes
Thank you!
