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PARTICIPANT INFORMATION

Full Name: {name}
Date of Birth: {dob}
Address: {address}
Phone Number: {phone}

Emergency Contact Name: {contact_name}
Emergency Contact Phone: {contact_phone}
Emergency Contact Relationship: {contact_relation}

HEALTH AND SAFETY INFORMATION

Do you have any serious pre-existing injuries, medical conditions, or physical limitations?

Do you have any allergies or medical concerns we should be aware of?

Do you have prior boxing or martial arts experience?
Yes
No

If yes, please describe your experience:

How did you hear about Bashta’s Martial Arts / Bullpen Combat Sports?

ASSUMPTION OF RISK

I understand that martial arts training, boxing, fitness training, strength training, sparring, and related physical activities involve inherent risks, including but not limited to:

• Bruises, cuts, and physical injury
• Muscle strains, sprains, and joint injury
• Concussions and head injury
• Serious bodily injury
• Permanent disability
• Death

I voluntarily assume all risks associated with participation in activities at Bashta’s Martial Arts / Bullpen Combat Sports.

I certify that I am physically fit to participate and have not been advised otherwise by a medical professional.

Initials:

RELEASE OF LIABILITY

I hereby release, waive, discharge, and hold harmless Bashta’s Martial Arts / Bullpen Combat Sports and its agents, including but not limited to:

John Bashta Jr.
John Bashta Sr.
CJ Dwyer
Josh Mais
and all coaches, instructors, staff, employees, contractors, and representatives

from any and all liability, claims, demands, or causes of action resulting from participation in martial arts, boxing, fitness training, or any related activities, whether on the premises or at any related event or activity.

I acknowledge that participation is voluntary and that I assume full responsibility for any injury, damage, or loss that may occur.

Initials:

MEDICAL RESPONSIBILITY

I understand and agree that:

• Bashta’s Martial Arts / Bullpen Combat Sports does not provide medical insurance
• I am responsible for maintaining my own medical insurance
• I am responsible for any medical costs incurred due to participation

Initials:

MEDIA RELEASE

I grant Joshua Mais and its agents permission to use my likeness in photographs, videos, or digital media for promotional, marketing, and educational purposes, including website and social media use, without compensation.

I understand that these materials become the property of Joshua Mais

I agree to the media release
I do NOT agree to the media release

Initials:

ACKNOWLEDGMENT AND SIGNATURE

I certify that I have read this agreement fully, understand its contents, and agree to all terms voluntarily.

Participant / Guardian Name:
Signature Date: {sign_date}

FOR PARTICIPANTS UNDER 18 YEARS OLD

I am the parent or legal guardian of the participant and consent to their participation and agree to all terms on their behalf.

Parent / Guardian Name:
Signature Date: {sign_date}