SOUTHSIDE MUAY THAI ACADEMY CORPORATION
TRAINING WAIVER
CONTACT & PERSONAL INFORMATION
FIRST NAME: ___________________________ LAST NAME: _____________________________ INITIALS:____
DATE OF BIRTH: _____/______/______ (DD/MM/YY) SEX: Male _____ Female _____
EMERGENCY CONTACT NAME: ____________________________ EMERGENCY CONTACT NUMBER: ____________________
How Did You Find Out About Southside MT? _______________________
DO YOU HAVE PREVIOUS MARTIAL ARTS EXPERIENCE? YES: ___ NO: ___
IF SO, WHAT, WHERE, HOW LONG, AND IF YOU STOPPED TRAINING THEN WHY?
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TO HELP US UNDERSTAND MORE ABOUT YOU PLEASE LIST ANY OTHER SPORTS, INTEREST, HOBBIES OR SKILLS YOU HAVE.
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MEDICAL HISTORY
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Do you have any allergies of any kind? Please state: ______________________________________
Have you had any recent or chronic injuries? Please state:_________________________________
Have you ever had any ailments, injuries, illnesses within the past 5 years that have caused you to
be away from work or school for 10 or more days? If yes please state: _______________________
Have you ever had high or low blood pressure, chest pain or tightness, or any heart disorder
including disorders of the circulatory system?
Have you ever had asthma or any respiratory disorders?
Have you ever had cancer, diabetes, liver disorders, disorders of the blood, hepatitis, kidney, or
intestinal disorders?
Have you had any conditions or therapies that could affect your immune system such as leukemia,
AIDS, HIV infection, radiotherapy or chemotherapy?
Have you ever had concussion, convulsions, loss of consciousness, fainting spells, severe headache,
nervous breakdown, mental illness, anxiety, depression, chronic fatigue syndrome, stroke, cerebral
palsy or disorder to the nervous system?
Have you ever had a backache, rheumatic fever, rheumatism, arthritis, paralysis, fibromyalgia, or
disorders of the muscle or bone, including joints, spine, and skin?
Will you be required for a surgical or medical treatment in the next 12 months?
Are you currently or recently gone off of taking any medications, non-prescription drugs, or any
herbal supplements of any kind? If yes please state: ______________________________________
INITIALS: ____
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RULES & REGULATIONS
One of our missions at Southside is to provide recreational, social and educational enrichment opportunities through quality training in Muay
Thai. The rules & regulations have been adopted to protect all the members’ right of access to the facility, to protect resources from damage,
and to promote love, respect and belief for all guests and staff.
The following conduct or behavior is not permitted at any time within Southside Muay Thai Academy premises or group excursions:
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Disorderly behavior of any kind, including excessive noise, vulgar, cursing or otherwise causing disruption to the peace and order
of the class. Be humble and respectful; treat others and you would want to be treated
Absolutely no physical/ verbal fighting and sexual activities will be tolerated within the vicinity of Southside Muay Thai Academy.
Harassment of other Southside Muay Thai Academy guests or staff, either verbally or physically is highly prohibited. This may
include verbal abuse, use of profanity or other abusive language, intimidations, staring at or following another person within the
facility, sexual harassment or harassment on the account of race, religion, ethnic background, gender or sexual orientation.
Refrain from training without proper protection. This includes gloves while hitting the bags or pads; and all safety equipment
must be worn while sparring (mouth guard, shin guards, cup, head gear, hand wraps and 14/16 Oz gloves)
Sparring without a Southside Muay Thai White Level or Instructor’s approval
Being reckless around hazardous areas while training (i.e. mirrors). Sparring near the mirrors, walls, poles, ring edge is not
allowed.
Vandalizing or defacing materials or property including equipment, furniture, walls or any other aspect of Southside Muay Thai
Academy is prohibited. Return all equipment once done (i.e. rental gloves, shin guards, weights, pads, skipping ropes etc.).
Removing materials, equipment or property from the building without authorization is prohibited.
Being unhygienic before, during, and/or after training. Clean and wash all personal and gym equipment with a proper disinfectant
(i.e. Gloves, shin guards, head gear, weights etc.)
Failure to clean up after oneself while using any part of the facility, this includes re-racking weights when finishing a set in the free
weights area may result in a penalty.
Possession of a camera phone in any of the locker room areas is prohibited
Indecent exposure, voyeurism, exhibitionism, or other lewd and lascivious acts is prohibited.
Training while being sick is highly ill-advised (we encourage optimal health for ALL the members)
Being reckless on or inside the ring. Bow before you enter and never enter under the bottom rope. Do not jump off the ropes, turn
buckles or perform any dangerous stunts with the ring.
Leaving trash or eating in the training studios is prohibited
Leaving personal property in the facility unattended. All property must be stored in a locker. Property left unattended will be
confiscated. Southside Muay Thai Academy Corporation is not held responsible for any personal items and valuable belongings that
goes missing; please place items in locker or secure visible place. Locker use are for gym hours only; any locks that are left
overnight without proper registration will be cut off.
Bringing firearms or any other deadly weapons into Southside Muay Thai Academy is extremely prohibited.
Bringing a bicycle into the facility must be put in the back of the workshop only. No bicycles are to be left near any of the
entrances.
No rollerblades, skateboards, inline skates, scooters or any other sports equipment that may cause damage to our floors are
allowed use in the facility.
No sleeping at the gym
Possessing or consuming alcohol or illegal drugs or being under the influence of alcohol or illegal drugs while at Southside Muay
Thai Academy is prohibited
No smoking tobacco products including any type of electronic cigarette, hookah, etc
Crossfit training is prohibited due to safety issues.
Selling products or services, soliciting for personal gain; or approaching guests for the purpose of obtaining signatures for
petitions within the building is prohibited
Posting or distributing unauthorized material or literature is prohibited. Approval must be obtained in advance from the Director
before proceeding.
Abandonment of individuals, both adults and children, who are unable to take care of themselves is prohibited. A responsible
guardian must attend to children under 16. The responsible adult must be within arms length of their children at all times unless
the child is participating in class.
Membership must be paid on time at the beginning of every month or end of every month.
No overnight parking
INITIALS: ____
MEMORANDUM OF AGREEMENT
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I, the undersigned parent or guardian, do hereby grant permission for my daughter/son, whose name is
_____________________, and hereinafter shall be referred to as “participant”, to participate in the activities and
exercises at Southside Muay Thai Academy Corporation.
I understand that Muay Thai and such other martial arts as the instructors and I include in the studies at the
Academy are martial arts; that is the systems of unarmed fighting
I acknowledge, understand and agree that Southside Muay Thai Academy Corporation activities and exercises are
strenuous whether training individually or participating in classes with other members and instructors. By joining the
exercises and activities I agree there is a possibility of physical illness, physical injury minimal, serious or
catastrophic (including but not limited to abrasions, bruises, bleeding, broken bones, cartilage or organ damage),
emotional or psychological injury, death, or property damage when used on people or equipment in the academy;
in addition, that the participant is assuming the risk by participating.
I understand that the types of injuries may result not only from intentional actions, but also from inadvertent,
negligent, or reckless action; performed by myself or others including the malfunction or failure of any of the
equipment or facilities at Southside Muay Thai Academy (including, but not limited to pads, protectors, punching
bags, and mats); and errors or mistakes in the instruction or performance of fighting or defense techniques by
instructors or other students at Southside Muay Thai Academy.
I understand that the risks of any and all the types of injuries described above cannot be significantly reduced or
eliminated without adversely affecting and even jeopardizing, the nature and quality of the instructions and
activities at Southside Muay Thai Academy
I further agree to hold Southside Muay Thai Academy Corporation and its Owners, Directors, Staff, or other
associated representatives including AI Insurance and any other subsequent body from any and all liability for
personal injury or property damage suffered on the grounds of the facilities. I also agree that Southside Muay Thai
Academy Corporation and its Owners, Directors, Staff, or other associated representatives including AI Insurance
and any other subsequent body do not authorize me to use any of the fighting or defense techniques that I learn in
my studies at Southside Muay Thai Academy against any other person, in any circumstances other than a) martial
arts training, matches, exhibitions, or demonstrations in which my instructors and I agree I am sufficiently
qualified and physically able to participate at Southside Muay Thai Academy or elsewhere; and b) self-defense or
defense of others in a situation that involves the risk of imminent physical injury or death. Furthermore, I
authorize the Owners, Directors, Staff or other associated representatives of Southside Muay Thai Academy
Corporation to act for me, according to their judgment, in any emergency requiring medical attention in the
facilities. I hereby hold the Owners, Directors, Staff or other associated representatives harmless in the exercise of
this authority.
I, the parent or guardian, understand that I will be notified as soon as possible in the event of an emergency. All
expenses of such treatment will be assumed by me or my insurance carrier.
I knowingly and voluntarily agree to assume all of the risks associated as stated above and hold harmless, and waive
any and all rights to initiate or maintain a lawsuit or otherwise seek or obtain any finding of liability against
Southside Muay Thai Academy Corporation and its Owners, Directors, Staff, or other associated representatives
including AI Insurance and any other subsequent body.
MEDIA/APPEARANCE CLAUSE: Permission is granted to use me or my child’s picture or image in any or all future
advertisements, broadcastings, web site, marketing literature or promotional videos for Southside Muay Thai
Academy Corporation and/or events sponsored and conducted by them.
By signing, I agree to follow the rules and regulations of the academy and agree to the terms of the agreement
stated above. Failure to adhere to the rules may result in immediate termination of membership, and in some
rare cases law-enforcement will be contacted and involved:
Participants Signature:_____________________________________________ Date:________________
If Participant is under 18 years of age:
Signature of Parent or Guardian:____________________________________ Date:________________
INITIALS: ____