3000 7 th Avenue Suite 1000 Altoona, PA 16602 814 505-2883 Agreement Name: DOB: Address: Home Phone: Cell Phone: Emergency Contact: Home Phone: Cell Phone: Participants Signature: Date of Signature: Referred by: Waiver of liability I hereby, acknowledge that as a participant of Scorchin Boxing Gym’s activities, I will be participating in activities that involve a risk of physical injury, included but not limited to full contact boxing. I further acknowledge that I know, understand and appreciate the risk of participation. I hereby release and hold harmless of Scorchin Boxing Gym, its officers, directors, shareholders, employees, landlord, related entities, agents, contractors, and staff from any and all liability, claims, damages, demands and other charges by reason of accident, damage to personal property, injury (including death), illness and other losses arises out of or related to directly or indirectly, participation of Scorchin Boxing Gym’s activities. I confirm that I maintain and am covered by Medical Insurance Policy, and agree to maintain said Policy or an equivalent Policy throughout the duration of my participation of Scorchin Boxing Gym’s activities. I give my permission to be taken to any hospital or medical care facility for any emergency or perceived emergency arising from or related to my participation in Scorchin Boxing Gym’s activities or occurring on Scorchin Boxing Gym’s premises, and to be treated by medical personnel on call or duty. I specifically release the members of Scorchin Boxing Gym, its officers, directors, shareholders, employees, landlord, related entities, agents, contractors, and staff from any and all liability, claims, damages, demands and other charges arising from or related to treatment and transport to treatment related to said emergency or perceived emergency. Further, I agree to indemnify and defend Scorching Boxing Gym, its officers, directors,
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3000 7th AvenueSuite 1000Altoona, PA 16602814 505-2883
Agreement
Name: DOB:
Address:
Home Phone: Cell Phone:
Emergency Contact:
Home Phone: Cell Phone:
Participants Signature:
Date of Signature:
Referred by:
Waiver of liability
I hereby, acknowledge that as a participant of Scorchin Boxing Gym’s activities, I will be participating in activities that involve a risk of physical injury, included but not limited to full contact boxing. I further acknowledge that I know, understand and appreciate the risk of participation.
I hereby release and hold harmless of Scorchin Boxing Gym, its officers, directors, shareholders, employees, landlord, related entities, agents, contractors, and staff from any and all liability, claims, damages, demands and other charges by reason of accident, damage to personal property, injury (including death), illness and other losses arises out of or related to directly or indirectly, participation of Scorchin Boxing Gym’s activities. I confirm that I maintain and am covered by Medical Insurance Policy, and agree to maintain said Policy or an equivalent Policy throughout the duration of my participation of Scorchin Boxing Gym’s activities.
I give my permission to be taken to any hospital or medical care facility for any emergency or perceived emergency arising from or related to my participation in Scorchin Boxing Gym’s activities or occurring on Scorchin Boxing Gym’s premises, and to be treated by medical personnel on call or duty. I specifically release the members of Scorchin Boxing Gym, its officers, directors, shareholders, employees, landlord, related entities, agents, contractors, and staff from any and all liability, claims, damages, demands and other charges arising from or related to treatment and transport to treatment related to said emergency or perceived emergency. Further, I agree to indemnify and defend Scorching Boxing Gym, its officers, directors, shareholders, employees, landlord, related entities, agents, contractors, and staff from and against any and all claims, damages, suits or cost of any nature (including reasonable attorneys’ fees) assessed or asserted against the same by an insurer, including but not limited to my own insurer, that in any way relate to my participation in activities at Scorchin Boxing Gym.
The foregoing has been read and its meaning explained to the above named participant, and I agree to the terms and conditions as stated.
Participant Signature:
Date of Signature:
1. Do not sign this waiver before you read it or if any space is intended for the agreed terms is blank.2. You are entitled to a copy of this waiver at the time you sign it (upon request).
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