Participation Form

Personal Information

Student’s Name *

Student’s Surname *

ID No *

Sex *

Date of birth *

Address *

Home Number

Work Number *

Cell phone *

Emergency Contact *

Emergency Contact Number *

Email Address *

Parent/Guardian

Parent/Guardian Name

Parent/Guardian Surname

ID No

Phone Number

Medical Information

Medical Aid *

Membership Number *

Family Doctor

Phone Number *

Please list any medical conditions or allergies that we should know about *

Additional Information

How did you hear about Self Defence Training Academy?

Do you know anyone who might benefit from being contacted by Self Defence Training Academy? Please fill in address below:?

Name

Email Address

Phone Number

Name

Email Address

Phone Number

Name

Email Address

Phone Number

Banking Details

Nedbank Cradlestone Mall
Branch Code - 198765
Account Number - 1084688964
Account type - Current Account
Reference - Name & Surname

Statement of Training

In the interest of safety, Self Defence Training Academy and its instructors require the following (please select Checkboxes):

I understand that whilst we teach very aggressive self defence tactics, safety is always our first priority and accidents are rare, but they can happen.

I/We agree to obey and follow safety rules and all instruction from instructors.

I agree to be responsible for my child’s behavior and his or her safety while on our premises; including parking lots, bathrooms, walking areas, etc.

I understand that full payment is due before training commences and proof of payment is required.

Payment is non-refundable.

Self Defence Training Academy does not carry insurance on any of its participants and I understand that obtaining insurance is my responsibility.

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

In consideration of participating in SELF DEFENCE TRAINING I represent that I understand the nature of this training and that I am qualified, in good
health, and in proper physical condition to participate in such training. I acknowledge that if I believe conditions are unsafe, I will immediately
discontinue participation in the training. I fully understand that this training involves risks of serious bodily injury, including permanent disability,
paralysis and death, which may be caused by my own actions, or inactions, those of others participating in the training, the conditions in which the
training takes place or the negligence of the “releasees” named below; and that there may be other risks either not known to me or not readily
foreseeable at this time; and I fully accept and assume all such risks and all responsibility for losses, cost, and damages I incur as a result of my
participation in the training.

I hereby release, discharge, and affirm not to sue SELF DEFENCE TRAINING ACADEMY, its respective administrators, directors, agents, officers,
volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable, owners and lessors of premises on which the training
takes place, (each considered one of the “RELEASEES” herein) from all liability, claims, demands, losses, or damages, on my account caused or
alleged to be caused in whole or in part by the negligence of the “releasees” or otherwise, including negligent rescue operations and further agree
that if, despite this release, waiver of liability, and assumption of risk I, or anyone on my behalf, makes a claim against any of the Releasees, I will
indemnify, save, and hold harmless each of the Releasees from any loss, liability, damage or cost, which may incur as the result of such claim.

I fully understand that Releasees are not physicians or medical practitioners of any kind. I hereby give permission to Releasees to render
temporary first aid to myself, child or children in the event of any injury or illness, and if deemed necessary by Releasees to call a doctor and to
seek medical help, including transportation by a Releasee to any health care facility or hospital, or the calling of an ambulance should Releasee
deem transportation to be necessary.

I have read the RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT, understand that I have given up
substantial rights by signing it and have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and
unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid the
balance, notwithstanding, shall continue in full force and effect.

I UNDERSTAND AND ACCEPT THE RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

YES

PARENTAL CONSENT

AND I, the minor’s parent and/or legal guardian, understand the nature of the above referenced training and the Minor’s experience and
capabilities and believe the minor to be qualified to participate in such training. I hereby Release, discharge, affirm not to sue and AGREE TO
INDEMNIFY AND SAVE AND HOLD HARMLESS each of the Releasees from all liability, claims, demands, losses or damages on the minor’s account
caused or alleged to have caused in whole or in part by the negligence of the Releasees or otherwise, including negligent rescue operations, and
further agree that if, despite this release, I, the minor, or anyone on the minor’s behalf makes a claim against any of the above Releasees, I WILL
INDEMNIFY, SAVE AND HOLD HARMLESS each of the Releasees from any litigation expenses, attorney fees, loss liability, damage, or cost any
Releasee may incur as the result of any such claim.

I ACCEPT PARENTAL CONSENT

YES

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While safety is always our first priority and accidents are rare, they can happen!

We look forward to training you.

Participation Form

Personal Information

Parent/Guardian

Medical Information

Additional Information

Banking Details

Statement of Training

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

PARENTAL CONSENT

While safety is always our first priority and accidents are rare, they can happen!

We look forward to training you.

Be Safe.