(ADF) Self Defense Course Agreement

Acapella Dance Fitness is now offering self-defense classes to males 8 years of age and up. Kids
class age ranges from 8-13 years of age. Adult classes are 13 years of age and up. Kids club area
is available for children. ADF Self Defense Class Membership offers walk in rates with class and
family packages available. The information below are the prices and packages offered. The
information below that is required in order to enroll.

Drop in Rates & Packages

Adults Kids
$15 $10
For groups of kids that reach 3+ the rates change to $25 for 3, $35 for 4, $45 for 5, and so on.

Primary Applicant Information

First Name: MI: Last Name:

Street Address: City: State: Zip:

Email: Phone: DOB:

Health Concerns:

Secondary Applicant Information (under 18 years of age)

First Name: MI: Last Name:
Street Address: City: State: Zip:

Email: Phone: DOB:

Health Concerns:

Emergency contact Info

Name: Phone: Relation:
(ADF) Self Defense Course Agreement

Liability
Release Form
Assumption of risk, Release of Liability for Personal injury, Agreement to Hold Business, Owner, Trainers,
Property Owners Harmless of fault.

I agree and consent to the following:

I am participating in self-defense classes at Acapella Dance Fitness LLC, conducted by ADF Trainer
Hamzah Howze. I recognize the classes require physical exertion that may be strenuous at times and
may cause physical injury. I am fully aware of the risks and hazards involved.

I understand it is my responsibility to consult with a physician prior to and regarding my participation in

the above-mentioned self-defense classes. I represent and warrant that I have no medical condition that
would prevent my participation in the above-mentioned self-defense class. I agree to assume full
responsibility for any risk injuries or damage known or unknown which might incur as a
result of participating in the above-mentioned self-defense classes.

I knowingly, voluntarily, and expressly waive any claim I may have against Acapella Dance Fitness LLC,
the owner Tahira Osama, Trainer Hamzah Howze, and property owners for any injury or damage
including death that I may sustain as a result of participating in the above-mentioned fitness classes or
caused by their negligence or other actions.

I, my heirs, or representatives' forever release waive, discharge and covenant not to sue Acapella Dance
Fitness LLC, the owner Tahira Osama, the trainers or property owners for any injury including death
caused by their negligence or other acts.

I have read the above waiver and release of liability and fully understand its content. I voluntarily
agree to the terms and conditions stated above.

If the participant is under 18 years of age, he must have the consent of parent/
guardian/accompanied adult who will read, understand, and take full responsibility to the above
terms.

_____________________________________________________________________________________
(print) Primary Member Name (signature) Primary Member Date

_____________________________________________________________________________________
(print) Member under 18 years Date