Informed Consent & Waiver Release Form

First name (participant)

Last name (participant)

Date of Birth (participant)

Full Name (Parent or Gaurdian)

Date of Execution

Partiticpants Name

I declare that the infomation I’ve provided above is accurate & complete.

By checking the box, I or the (parent or guardian if client is under 18 yrs old) on behalf of (minor or child under 18) hereby affirm that I am entering a program of instruction in wrestling training. By enrolling in this academy / program I certify that I am cognizant of all of the inherent dangers of wrestling training and the basic safety rules for activities connected herewith. I understand and agree that neither the program nor its operator, instructor, owner, including but not limited to Tom Shifflet and / or Shifflet Fit LLC may be held liable in any way for any occurrence in connection with my wrestling and performance which may result in injury, death or damage to me or my family, heirs or assignees. I further acknowledge and forever release Tom Shifflet and Shifflet Fit LLC in connection with directly or indirectly with my wrestling and performance training as a result of Tom Shifflet and Shifflet Fit LLC own negligence, which may result in injury, death or damages to me or my family, heirs or assignees. In consideration of being allowed to enroll in this program I hereby personally assume all risks connected with the training, equipment, training environment and I further release the instructor, program, agents and operator, including but not limited to the persons mentioned for any injury or damage which may be incurred by me while I am enrolled in the wrestling or performance training including all risks connected therewith, whether, foreseen or unforeseen; and further to save and hold harmless the program and persons from any claim by me, or my family, estate, heirs or assignees, arising out my enrollment and participation in this wrestling training. I further state that I am of lawful age and legally competent to sign this aforementioned release; that I understand that the terms herein is contractual and not a mere recital; and that I have signed this document as my own free act. I have fully informed myself of the contents of this aforementioned and release by reading it before I sign it, I have been advised to submit, at my own expense and time, to a medical examination to ensure myself, and assume my own responsibility of physical fitness and capability to perform under the normal conditions of the wrestling program, and am physically fit as tested by a medical examination. I also understand that the owner / trainer reserves the right of membership / participant(s). I understand and have fully informed myself (and participant if under the age of 18) of the training / coaching background and experience Tom Shifflet does possess and hereby forever release Tom Shifflet and or Shifflet Fit from any liability for bodily injury or death of participant(s) and damage to personal property belongng to participant(s).

Payment Options - Please select only one

I agree to make (1) cash payment for the wrestling supplimental training. I understand that payment is due at the start of the first wrestling training session.

OR

I agree to make (1) venmo payment for the wrestling supplimental training. Payment is due today using the Venmo account provided below.

By clicking the box, I understand that NO REFUNDS will be issued due to missing any of the scheduled workouts.

Open your Venmo App and scan the QR CODE for @Flow-716. Next please add the participants name along with "Wrestling Academy" in the notes section within the Venmo App before sending the payment.

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Informed Consent & Waiver Release Form

Payment Options - Please select only one

OR