PRMAA Waiver & Terms Pacific Rim Martial Arts Academy waiver and acceptance of terms. This form MUST be fully completed prior to participating in any PRMAA classes. Step 1 of 3 33% PRMAA Membership* New Member Renewing Member Upgrade Welcome to the Pacific Rim Martial Arts Academy. Before participating in any event, class, or activity, you must first complete and submit this form in it's entirety. You may complete this form for yourself and any immediate family members who are part of your membership. Before completing the form, please indicate whether you are a new or returning member of PRMAA.Enrollee Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth MM slash DD slash YYYY AgePlease enter a number less than or equal to 100.Gender Male Female Primary PhoneAlternate PhoneEmail Employer Occupation Friend or relative not living with you: First Last Phone number for contact above:OPTIONAL: Use the fields below to add additional family members to your membership.Name First Last Date of Birth MM slash DD slash YYYY AgePlease enter a number less than or equal to 100.Gender Male Female OPTIONAL: Add a family memberName First Last Date of Birth MM slash DD slash YYYY AgePlease enter a number less than or equal to 100.Gender Male Female OPTIONAL: Add a family memberName First Last Date of Birth MM slash DD slash YYYY AgePlease enter a number less than or equal to 100.Gender Male Female WAIVER The agreement entered into on the date shown below by and between Pacific Rim Martial Arts Academy Incorporated (Pacific Rim) and the Enrollee is as follows: The enrollee understands the procedures and exercises involved in instruction and participation as explained to him/her by a representative of Pacific Rim. The Enrollee understands that there is a risk of personal injury involved in the course of instruction and with this knowledge agrees to indemnify and hold harmless Pacific Rim from all losses caused by accident or injury to the Enrollees, or to third persons who may be Enrollees of Pacific Rim, in the event that either the Enrollee or said third person is injured in any way during the instruction and/or performance of exercises. Because of the physical demands of class instruction, Enrollee understands that he/she must be in good physical condition to participate in said course of instruction and hereby certifies that he/she is in good physical condition. It is further agreed that if the enrollee fails to make any payment due hereunder, or any part thereof, Pacific Rim may at its option, without notice or demand, declare the then unpaid balance to be immediately due and payable together with all costs of collection, including but not limited to, a reasonable attorney's fee, including attorney's fees in the trial court, on appeal, or in any bankruptcy proceeding.By checking the box, I agree to the terms set forth in the above Waiver.* I agree. MEDICAL HISTORYGeneral Health: Excellent Good Fair Poor Date of last physical exam: MM slash DD slash YYYY Medical Problems? Yes No If "Yes" above, please explain:Taking Medication? Yes No If "Yes" above, please explain:Additional medical information you want to disclose:
