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radKIDS Parental Consent and Participant Wellness Form

 

 

My signature hereby acknowledges to radKIDS, Inc. and its radKIDS
Instructor or Instructors:

That my son/daughter and I are aware of the physical nature
and possible risks of injury incident to taking this practical
course in personal safety; That he/she is physically fit to participate
in this course, involving various physical techniques;
and, we realize that such techniques cannot be successfully employed
in every situation, and proficiency can only be achieved
through continued practice, exercise of good judgment, and a
person’s natural ability.

I also understand that sensitive subject matter will be discussed
and is in the Parent’s Manual for my review.

My signature also releases radKIDS, Inc., and its radKIDS Instructor or Instructors,
and sponsor, and agrees to hold them harmless, from any liability
for injury that may be incurred as a result of this course, or use of the strategies
within.

I have read the above waiver and release. I understand that there are physical skills and activities in this program. I sign voluntarily and authorize my son / daughter to attend the upcoming self esteem and personal empowerment safety education program offered by radKIDS, Inc. course at the Alaska Moving Arts Center

The Information submitted is complete, true and accurate to the best of my knowledge.

______________________Instructor's check

Please select who will be participating...
Minor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
Please check one
New radKID Student
Returning radKID Student
I grant permission for my child's picture to be taken for the purpose of the graduation certificate and/or general media or press release from the radKIDS program
Yes, I grant permission
No, I do not grant permission
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive AMAC class information
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
WELLNESS INFORMATION FOR radKIDS Confidential Medical History

1. Height and weight of participant (approx)
2. Gender*
Male
female

3. Date of most recent medical examination
4. Do you feel fine, without restriction?*
No
Yes

If no, please describe
5. Has he/she ever been hospitalized or treated for an injury?*
No
Yes

If yes, please describe:
6. Has he/she ever been injured and not received medical attention?*
No
Yes

If yes, please describe:
7. Does he/she have any current medical conditions which are currently being treated?*
No
Yes

If yes, please describe:
8. Is he/she currentoy using any prescription drugs?*
No
Yes

If yes, please describe
9. Does he/she have any known allergies?*
No
Yes
Does he/she have difficulty breathing?*
No
Yes
Does he/she have high blood pressure?*
No
Yes
Does he/she have diabetes?*
No
Yes

If yes, to any of the above please describe

10. How frequently does he/she exercise? and What type of exercise?
11. Has he/she ever been involved in self-defense or Martial Arts Training?*
No
Yes

If yes, please describe

12. Please describe your perception of his/her current fitness level
How did you hear about radkIDS?
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Please check one
New radKID Student
Returning radKID Student
I grant permission for my child's picture to be taken for the purpose of the graduation certificate and/or general media or press release from the radKIDS program
Yes, I grant permission
No, I do not grant permission
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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