Adults Waiver Form Note: You can save this form to fill in later (see end of form). Your contact detailsYour name* First Last Your email address* Mobile*Home phonePostal address* Street Address Suburb Postcode About youThis information is necessary to ensure your safety, and the safety of others in the class. No medical information will be divulged to others unless necessary for the running of the class.Your date of birth* Date Format: DD slash MM slash YYYY Please select all that apply:* Have you had recent surgery? Do you have high blood pressure? Do you have epilepsy? Are you on any medications? Do you have diabetes? Do you have a heart condition? Do you often feel faint or dizzy during exercise? Do you have any allergies? Do you have a condition not listed above? NO MEDICAL ISSUES Please provide details of your condition/s listed abovePhotographyFrom time to time we may take photographs and video footage of the classes for promotional purposes including social media, printed materials, our website, and other online advertising.Authorisation*I authorise the use of my image for the above purposesI DO NOT authorise the use of my image for the above purposesAssumption of risk/waiverI hereby enrol in Kickstarters self defence training on the basis of the terms and conditions set out below:Please read and select all terms* I acknowledge that the training, while conducted in the safest possible conditions and under qualified supervision, involves physical contact and inherent risks and I accept those risks. I agree to conduct myself in a safe and mature manner and in accordance with the instructions of my instructors. I indemnify Kickstarters and Roaring Sky Sharks Pty Ltd including all instructors, staff members, and students against any loss or damage suffered by them in connection with my participation in the training. I confirm that I am physically capable of participating in this training and that I have no existing medical condition which precludes or should reasonably preclude my participation. I agree to release Kickstarters and Roaring Sky Sharks Pty Ltd, including all instructors, staff members, and students from any liability whatsoever in connection with my participation in this self defence training program. Without limitation, this includes all loss or damage or injury incurred as a direct or indirect result of my participation. Your signature*I agree to the above terms and conditionsDate Date Format: DD slash MM slash YYYY EmailThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.