Capoeira Exercise Disclaimer-Waiver form

Full Name*

First NameLast Name

Date of Birth*

MonthDayYear

Phone Number*

Country CodeArea CodePhone Number

E-mail*

City:*

Have you done Capoeira before?*

YesNo

Capoeira Instructor:

Which Capoeira School

Emergency Contact*

First NameLast Name

Emergency Phone Number*

Country CodeArea CodePhone Number

Regular exercise is associated with many health benefits, yet any change of activity may increase the risk of injury. Completion of this questionnaire is a first step when planning to increase the amount of physical activity in your life. Please read each question carefully and answer every question honestly:

1) Has a physician ever said that you have a heart condition & should only exercise supervised by a doctor?*

YesNo

2) Do you feel pain in your chest when you are physically active?*

YesNo

3) Have you had chest pain in the past month while being physically not active?*

YesNo

4) Do you ever lose consciousness or do you lose your balance because of dizziness?*

YesNo

5) Do you have a joint or bone problem that might get worse by a change in your physical activity?*

YesNo

6) Are you taking any prescribed medication for your blood pressure or heart condition?*

YesNo

7) Are you pregnant?*

YesNo

8) Do you have insulin dependent diabetes?*

YesNo

9) Are you 60 years of age or older and not used to being physically active?*

YesNo

10) Do you know of any other reason why you should not exercise or increase your physical activity?*

YesNo

If you answered “yes” to any of the above questions, talk with your doctor by BEFORE you become more physically active. Tell your doctor your intent to practice CAPOEIRA.

If you honestly answered “NO” to all questions above you can be reasonably positive that you are safe to gradually become more physically active.

By submitting this disclaimer, I understand and agree:

1. That I am participating in the CAPOEIRA training, programs, exercises and events offered by LEVEL UP SKILLS FZ
2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any fitness program. I certify and warrant that I am physically fit and I have no medical condition that would prevent my full participation in this class
3. In consideration of being permitted to participate in any CAPOEIRA training I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of my participation in the program
4. In consideration of being permitted to participate in any CAPOEIRA program I knowingly, voluntarily, and expressly waive any claim I may have against LEVEL UP SKILLS FZ and any of its instructors, owners, landlords or insurers for an injury/injuries or damages that I may sustain as a result of my part taking in the program
5. I, my heirs or legal representatives forever release, waive, discharge, and covenant not to LEVEL UP SKILLS FZ and any of its instructors, owners, landlords or insurers for any injury or death caused by their negligence or other acts.

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

Participant Name*

Capoeira by LEVEL UP SKILLS FZ