Please select all that apply.
Please enter an email where you can receive class notifications and updates about your workshop(s)..
Do you have a nick name, go by your middle name, is there a specific pronunciation of your name? Let us know here.
Please enter a number we can use to contact you, via phone or text, in case of emergency workshop(s) cancelations or other important notifications.

Please read all statements below carefully before completing this form.

We are actively seeking to create and support truly diverse membership, including but not limited to members of all racial and ethnic backgrounds, all gender identities, all sexual orientations, and any other identity characteristics to strengthen the work and the reach of the organization.

We will not tolerate or allow discrimination against any of our members or participants. If there are claims of discrimination, ASSERT Empowerment Self Defense will adhere to a three-step process, consisting of an official investigation into the suit, remediation of the wrongful behavior(s), and a resolution policy. When a claim is brought forth, a third party will be brought in to validate and substantiate the claim. If a claim is found to be groundless or to have been made out of malice, the reporting member will be suspended from membership for no less than one year up to permanent expulsion from the organization.

I, the undersigned, HEREBY WAIVE AND RELEASE, indemnify, hold harmless and forever discharge ASSERT Empowerment Self Defense and its agents, employees, officers, directors, affiliates, successors and assigns, of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages and liabilities, of every kind and nature, whether known or unknown, in law or equity, that I ever had or may have, arising from or in any way related to my participation in any of the events or activities conducted by, on the premises of, or for the benefit of, ASSERT Empowerment Self Defense provided that this waiver of liability does not apply to any acts of gross negligence, or intentional, willful or wanton misconduct.

I understand that the activities that I will participate in are inherently dangerous and may cause serious or grievous injuries, including, but not limited to, bodily injury, damage to personal property, sprains, contusions, abrasions, broken bones, and, in extreme cases, paralysis and/or death. Due to the potential hazards associated with the activities of the program, I/We recognize the importance of following the instructions regarding fitness/martial arts/ self-defense techniques and other rules associated with the program.

On behalf of myself, my heirs, assigns and next of kin, I waive all claims for damages, injuries and death sustained to me or my property, that I may have against the aforementioned released party to such activity.

By this Waiver, I assume any risk, and take full responsibility and waive any claims of personal injury, death or damage to personal property associated with ASSERT Empowerment Self Defense including but not limited to receiving lessons at the facility, using the facility and its equipment, practicing and/or engaging in marital arts or other related activities on and off the premises.

This WAIVER AND RELEASE contains the entire agreement between the parties, and supercedes any prior written or oral agreements between them concerning the subject matter of this WAIVER AND RELEASE. The provisions of this WAIVER AND RELEASE may be waived, altered, amended or repealed, in whole or in part, only upon the prior written consent of all parties.

I have read, understand and fully agree to the terms of this WAIVER AND RELEASE. I understand and confirm that by signing this WAIVER AND RELEASE I have given up considerable future legal rights. I have signed this Agreement freely, voluntarily, under no duress or threat of duress, without inducement, promise or guarantee being communicated to me. My signature is proof of my intention to execute a complete and unconditional WAIVER AND RELEASE of all liability to the full extent of the law. I am 18 year of age or older and mentally competent to enter into this waiver.

Infectious Disease and Injury Agreements

In consideration of my participation in the foregoing, the undersigned acknowledge and agree to the following:

The World Health Organization and the U.S. Centers for Disease Control have declared the novel Coronavirus (COVID-19) a worldwide pandemic, and more may be on the rise. Due to its capacity to transmit from person-to-person and other seasonal viral communicable diseases, the government sets recommendations, guidelines, and some prohibitions which ASSERT Empowerment Self Defense and all program participants will observe as issued.

I, nor any member(s) of my household, have not experienced symptoms that of fever, fatigue, difficulty in breathing, or dry cough or exhibiting any other symptoms relating to COVID-19 or any communicable disease within the last 14 days.

I, and all members of my household, are following all CDC recommended guidelines as much as possible and limiting our exposure to the Coronavirus/COVID-19. or any other communicable disease. Personal Responsibility.

I am aware of the existence of the risk to our physical appearance, to the venue, and to our participation in the activity of the Organization that may cause injury or illness such as, but not limited to Influenza, MRSA, or COVID-19 that may lead to paralysis or death.

I have not, nor any member of my household, visited any area within the United States that was reported to be highly affected by COVID-19 or any other communicable disease, in the last 30 days.

I have not, nor any member(s) of my household, traveled by sea or by air, to high-risk areas, domestically or internationally, within the past 30 days.

I have not been, nor any member(s) of my household, diagnosed to be infected of COVID-19 virus within the last 30 days. CDC Recommendations Agreements .

Personal Responsibility

Following the pronouncements above I hereby declare the following:
All are required. Please read each item carefully and check to confirm that you have read, understand, and agree to each.

Workshop Details

Please let us know which workshop(s) you will be attending. If you are attending a series of classes, please select the series starting date.
Let us know the location of the workshop that you have selected.

Emergency Contact Information