The parent/legal guardian of the enrollee is aware in making this agreement to have their child participate in training in the self-defense that certain elements of this training are physically demanding and potentially dangerous, and with this knowledge agrees to indemnify and hold harmless from all losses caused by accident or injury the Building Communities First, Nation Builders, Inc., Mr. Mason West III, the Instructor, his assistants, or any third parties who may be parents/legal guardians of enrollees of the same class or seminar or who are students with the Instructor, in the event that the enrollee or the said third party is injured in any way during the proper performance and execution of techniques or instruction provided in this training. (check box)

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This release shall also include any landlord or leaseholder of any training facility in which training is conducted. I also agree that the terms hereof shall serve as a release and assumption of risk for my heirs, executors and administrators, and for all members of my family, including any minors.

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Student's Name: *

Parent's Email: *

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As part of the consideration for participation, the parent/legal guardian of the enrollee acknowledges and assumes all these risks and wishes to enroll in this course of instruction. Please type name below to indicate agreement.

Parent's Name: *

Parent's Mobile Number: *

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The parent/legal guardian of the enrollee attests that he/she is in good physical condition and has no known or suspected medical conditions that would preclude vigorous physical activity.

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Address where student resides: *

I hereby grant permission to the rights of my child’s image and likeness without payment or any other consideration. I understand that the image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the image. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.

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Student's Grade for 2019-2020: *