Registration / Application For your Membership at Clinch MMA

Physical Activity Readiness Questionnaire and Waiver

Our exercise program offered by Clinch MMA has been designed to provide the optimum level of exercise and enjoyment without compromising the health or safety of its member. I understand that the exercises must be executed in the proper manner in order to eliminate the risk of injury. I acknowledge the need to follow the rules and instructions of Clinch Muay Thai instructors and I undertake to follow these rules and instructions and abide by them. In consideration of my becoming a member of Clinch MMA, I myself, my heirs, executors, administrators, successors and assigns, do hereby release and forever discharge, waive and save harmless, protect and keep indemnified, Clinch MMA and all their respective agents, employees and representatives from and against any and all kinds of action, claims, costs, expenses and demands in respect to death, injury, loss and damage to my person or property however caused and arising out of my being permitted to attend all in any way prior to, during or subsequent to programs and/ or activities as a member.

Physical Activity Readiness Questionnaire and Waiver

Terms and Conditions I

Terms and Conditions II

You acknowledge that you voluntarily participate in training at Clinch MMA. You understand that there are inherent risks associated with physical activity and training in martial arts, including but not limited to the risk of injury. You also understand that Clinch MMA is not responsible for any lost or stolen items.

Therefore, you waive and release Clinch MMA and its owners, employees, agents, and representatives from any and all liability for any lost or stolen items or injuries that may occur as a result of my participation in training at Clinch MMA. You acknowledge that you are solely responsible for my personal belongings and for your own safety during training.

You understand the terms of this waiver and voluntarily sign it, intending to be legally bound.

Full Name

Full Address

Occupation

Date of Birth (MM/DD/YYYY)

Emergency Contact

How did you hear about our school

Previous Martial Arts experience:

Your goal or reason for training

Do you have any reason why you should not be exercising? (Yes / No. If yes, please describe)

Do you have any medical conditions?

Do you have any communicable diseases? (i.e. Ringworm, Hepatitis B, or HIV)

Have you ever had a fracture or dislocation? (Yes / No. If yes, when? MM/DD/YYYY)

Do you have any past history of back, neck or joint injuries? (Yes / No. If yes, please describe)

Have you ever had a sprain or strain? If yes, when? (Yes / No. If yes, when? MM/DD/YYYY)

Do you have any past history of Asthma or Diabetes? (Yes / No)

Have you ever been hospitalized? If yes, when? (Yes / No. If yes, when? MM/DD/YYYY)

Have you ever passed out or experienced chest pains? If yes, when? (Yes / No. If yes, when? MM/DD/YYYY)

Have you ever been told you have high blood pressure? (Yes / No)

Have you ever felt dizzy while exercising? If yes, when? (If yes, is this something we should be concerned about?)

Have you ever had numbness or tingling in your arms, hands or feet? (Yes / No)

Have you ever had a head injury or concussion? If yes, when? (Yes / No. If yes, when? MM/DD/YYYY)

Have you ever been knocked unconscious? If yes, when? (Yes / No. If yes, when? MM/DD/YYYY)

By Completing this application, you declare that you have truthfully completed this document including the Physical Activity Readiness Questionnaire.

By saying yes below, you 100% agree and acknowledge both Terms and conditions set out in the beginning of this page

Teaching MMA since 2008.

Clinch MMA is located in Port Coquitlam, B.C., consisting of Brazilian Jiu Jitsu (BJJ) and Muay Thai Kickboxing. Clinch MMA incorporates conditioning, submission fighting, combat training, grappling techniques, judo throws, boxing, and self-defense. Clinch MMA is a full conditioning center with state of the art equipment that can accommodate classes for all levels; junior, kids, teen, adult, ladies, beginners and advanced levels.