FAITH MMA

3129 Duckett Mill Road Gainesville, GA 30506 Located in the gym of the campus of Lanier Hills Church (404) 375-6087 www.myspace.com/faith_mma

RELEASE/AUTHORIZATION FORM
Note: This statement must be signed by a parent or guardian for a minor, or by the registrant if an adult, and by Faith MMA’s head trainer. I, the parent/guardian of the registrant, a minor, or adult registrant of legal age, agree that I and the registrant will abide by the rules of Faith MMA. I also agree to wear the required safety gear during training sessions with Faith MMA, including but not limited to, a groin protector and mouth-guard. Recognizing the possibility of physical injury and possibility of spreading blood-borne illnesses associated with MMA training and sports-related activities and in consideration for Faith MMA accepting the registrant for their MMA training and sports-related activities, I hereby release, discharge and/or otherwise indemnify Faith MMA, their affiliated organizations and sponsors, employees and associated personnel, against any and all claims by or on behalf of the registrant as a result of the registrant’s participation in the MMA training and sports-related activities offered by Faith MMA. Faith MMA and our trainers do recommend that participants get tested for blood-borne illnesses and consult their regular physician before starting an MMA training regimen. MMA training is a strenuous activity and a clean bill of health from a physician is highly recommended before beginning an MMA training regimen. Currently, the state of Georgia does not require amateur fighters or participants in MMA training programs to get tested before starting an MMA training regimen, but we at Faith MMA recommend it for the safety of the other Faith MMA fighters, participants, and trainers in our MMA training and sports-related activities. Parent/Guardian Signature: __________________________________________________________ Date: ___________________________ Registrant Signature: _______________________________________________________________ Registrant’s Name (please print): ______________________________________________________ Address: _________________________________________________________________________ Phone Number: ____________________ Age: _______ Email Address: ____________________________________________________________________ In case of an emergency or accident, please provide emergency contact information below: Name: ___________________________________________________________________________ Phone Number: _____________________ If you have any questions, please call Micah at (404) 375-6087 or speak with him during a Faith MMA training session. Faith MMA Head Trainer Signature: ____________________________________________________

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