Fillable LJFA STUDENT SAFETY WAIVER

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LJFA STUDENT SAFETY WAIVER

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LJFA STUDENT SAFETY WAIVER
STUDENT INFORMATION
Name: __________________________________________________________________________
Date of birth: _______________________________________ Male/Female: __________________
USA Fencing#: ___________________________________________________________________
Medical conditions or health concerns we should be aware of (asthma, ADD/ADHD, etc.):
________________________________________________________________________________
CONTACT INFORMATION
* This information is solely for when we need to contact you. We do not disclose any personal
information to third parties.
Parent/guardian (if student is under 18): ________________________________________________
Mailing Address: ______________________________________City_____________Zip__________
Phone(S): Home: _____________________________ Work: _______________________________
Cell: _______________________________________ Other: _______________________________
Parents Email: _______________________________ Student’s Email: _______________________
Emergency contact (if different from above)
Name: ______________________________________ Relationship: _________________________
Daytime phone: _______________________________ Evening phone: _______________________
PARTICIPATION AGREEMENT
I understand that violation of La Jolla Fencing Academy rules and guidelines may result in not being
able to participate in some or all class activities. I further understand that La Jolla fencing Academy
reserves the right to remove a participant from a class if necessary.
Student signature: _____________________________ Parent signature: _____________________
***All classes nonrefundable after the date of the first class.
PLEASE SIGN THE BACK PAGE
Release and Waiver of Liability, Assumption of Risk, And Indemnity Agreement
("Agreement").
In consideration of the opportunity to participate in the fencing activities of La Jolla Fencing Club, I, the undersigned, for
myself, my personal representatives, assigns, heirs and next of kin:
1.I attest that I am physically and mentally fit to participate in the art and activity of fencing and voluntarily assume all risks
of loss, damage or injury that may be sustained while participating in the activities of the La Jolla Fencing Academy
2.I understand that serious accidents can occur during fencing, and that participants can sustain serious personal injuries
and/or property damage as a consequence thereof. Knowing the risks of fencing, I nevertheless hereby agree to assume
those risks and to release and hold harmless all of the persons and entities mentioned above who, through negligence or
carelessness or otherwise, might be liable to me (or my heirs, personal representatives or assigns) for damages.
3. I understand that the La Jolla Fencing Academy, its owners, officers, directors, instructors and members (collectively
"La Jolla Fencing Academy") make no representation regarding the safety, suitability, and compliance with industry
standards of the fencing equipment owned, used, and made available for use to and by the La Jolla Fencing Academy for
its members and non-members. I hereby specifically release and waive the aforementioned parties from any and all
liability arising from and in connection with my use of the La Jolla Fencing Academy equipment.
4.I hereby waive and release any and all claims for damages, for death, personal injury, loss of property or property
damage I may have, or that may subsequently accrue to me, as a result of my participation as a member or a non-
member in the activities of the La Jolla Fencing Academy.
5.I discharge and release in advance the La Jolla Fencing Academy, from any and all liability arising out of or connected
in any way with my participation in the activities of the La Jolla Fencing Academy; including, but not limited to, instruction,
training, lessons, bouts and competitions. My participation is voluntary and done at my own risk.
6.I hereby consent to any emergency medical treatment needed. I understand and agree that medical or other services
rendered to me by, or at the instance of, any of the persons or entities mentioned above is not an admission of liability to
provide or to continue to provide any such services, and is not a waiver by any of the persons or entities mentioned above
of any right hereunder.
7.If, despite this Agreement, I or anyone on my behalf makes a claim against any of the releases, I will indemnify, save
and hold harmless each of the releases from any litigation expenses, attorney’s fees, loss, liability, damages, or costs
which they may incur as a result of such claim.
8.I agree to accept and abide by the rules and regulations of the United States Fencing Association (“USFA”) and the
USFA San Diego Division.
9.I agree to conduct myself in a courteous manner while I participate in the activities of the La Jolla Fencing Academy. I
agree to treat other La Jolla Fencing Academy fencers with respect and to observe proper fencing etiquette while on the
fencing strip during training, lessons, and/or competitions.
10. I hereby grant the La Jolla Fencing Academy permission to use my likeness in a photograph, video, or other digital
media (“photo”) in any and all of its publications, including web-based publications, without payment or other
consideration. I understand and agree that all photos will become the property of La Jolla Fencing Academy and will not
be returned.
I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I
AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN MYSELF
AND THE LA JOLLA FENCING ACADEMY AND ITS MEMBERS, AND I HAVE SIGNED IT
VOLUNTARILY.
Student/Parent Signature (if Student is younger than 18): ________________ Date: _____________
Insurance company: ________________________________________________________________
Policy number: ____________________________________________________________________
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LJFA STUDENT SAFETY WAIVER

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Completed 20 September 2021

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