SAVAGE Andy Jarvis Yoga & Muay Thai Disclaimer & Medical

Please read the disclaimer below and then acknowledge you have read and understand and sign.

This must be done before you can participate in Classes, PTs, Yoga, Massage or any other sports or therapeutic practices at SAVAGE GYM, Flow Stone Wellness Studio, your Domicile or any other Facility and or with/supervised by Andy Jarvis.

I, the student/trainee/parent/guardian agree and understand that whilst training/practicing/receiving a therapeutic service without my own insurance, no liability what so ever is attached to Savage Fight Gym Ltd, or any of its instructors, coaches, teachers or therapists for any occurence/accident causing injury, damage or death to any person or person’s, or property that may arise whilst attending any activities otherwise within or about the premises.

I, as The customer/student/practitioner (or my child/ward) have no known medical illness, disability or take any medication which prohibits or impedes me (or them) from participating in the activities, services and functions of the gym/club that has/have not been declared below. I understand that the information on this form will be used for gym/studio/club purposes including and not limited to communication on classes and events, and will not be passed on to any 3rd party without prior consent.

I acknowledge that for PTs and 121s Andy Jarvis operates a 24hour Fair (obvious mitigating circumstances ofcourse allowed) Cancellation or Full charge policy and a maximum of 2 Reschedules before a Full Charge may be applied and a new session must be booked . 5 blocks must be booked within 30days of payment and 10 blocks within 60days. Thankyou for your understanding.

First name

Last name

Phone

Physical Contact Consent*

Yes

Do you acknowledge and understand that Muay Thai, K1, Boxing, Yoga and Sports massage involves reasonable physical contact, especially contact sports and massage, and you consent to this. We acknowledge that you may withdraw your consent at any time verbally and by writing to/emailing/messaging us. You understand that if you answer No, we will be unable to work on a 121 or group basis with you.

** For the Purpose of Private 121 Gym, Home Visit and Hire Studio Yoga tuition 121 and/or Muay Thai PT 121, Massage** (only fill out if this applies to you)

Yes

Do you provide consent for attendance to your personal domicile, or that you are happy to attend the gym or a studio for the sole purpose/s of practicing and receiving tuition in Yoga and or Muay Thai (assuming a suitable space is available for yoga practice/PT) and that by doing so you are acknowledging and making clear that you are comfortable working on a one to one basis with your tutor/guide/coach in your own home or at an agreed suitable space hired by the same.

Are you (or your child/ward) a Member of Savage Gym*

Yes

Emergency Contact Name*

Emergency Contact Number *

Do you (or your child/ward) have Insurance to Train Muay Thai, Yoga or any other Sport/Martial Art*

Yes

Date of Birth (or D.O.B of Child/Ward) *

Month

Day

Year

Ailment/Injury Declaration*

Have you (or your child/ward) any Ailments, Infirmities, Medical Issues, Injuries or Conditions that might impede, affect, or put you or others at risk when training, as a result of training, or when receiving a holistic or therapeutic service.

I.e. Heart, Brain, Spine, Blood Pressure, Mental Health, Skin condition etc.

If No put N/A

Do you understand and agree that by training with or without an Ailment, Medical Condition or Injury that you are still fully responsible for your (or that of your child/ward) own safety, must listen to your body, identify and honour its limitations and that injury or further injury is always a possibility, particularly with combat sports.

If signing on behalf of a child/ward Please tick to show that you have Fully Read and Understood and that you agree to the terms of this Form.

Please Sign to show that you have Fully Read and Understood and that you agree to the terms of this Form.*

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ANDY JARVIS | YOGA & MUAY THAI MAIDSTONE & MEDWAY

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