Medical Release Form

I hereby authorize dba: Capoeira Evolução to provide me with medical care, treatment and emergency medical services associated with participation in this program. In addition, I agree to pay all the costs associated with my medical treatment or transportation. I further authorize the release of any medical information necessary to process a claim for accident/medical payment insurance for an injury or illness incurred while participating as a member of Capoeira Evolução program.

The undersigned, parent or legal guardian of the participant represents he/she is in fact acting in such capacity and agrees to save and hold harmless Grupo Capoeira Evolução, City of Austin, or their respective coaches, instructors, officers, directors, agents, representatives, or employees for any and all damages that may be sustained or suffered by me in connection with, or arising out of my traveling to, participating in, and returning from the Grupo Capoeira Evolução program. I also agree to indemnify and hold harmless Grupo Capoeira Evolução, City of Austin, or their respective coaches, instructors, and all related entitles for any damages incurred arising from any claims, demand, action, or clause of action by the participant.

In the event I am injured or should require medical attention, I hereby authorize dba: Capoeira Evolução to contact a physician. In the event the doctor cannot be reached, I hereby authorize the coach or other Capoeira Evolução representative to secure necessary medical treatment. If possible, confirmation of this authorization should be made with me prior to treatment, by calling me at the numbers listed on this form. In case I cannot be reached, or in case of emergency, medical treatment as described may proceed without further authorization.

A copy of this form will be sent to the email provided below.

Date:

Student Name:

Student Email:

If participant is under age, the Parent of Guardian must accept the following waiver

This is to certify that I as parent/guardian of the participant in the Capoeira Evolução program, give my consent to dba: Capoeira Evolução and its representatives to obtain medical care from any licensed physician, hospital, or clinic for the above mentioned athlete for injury that could arise from activities in this activity.

Parent or Guardian:

Phone:

Acceptance* (required)

*By checking this form I understand that my participation in the sport of capoeira carries a risk of serious injury, including permanent paralysis or death. I voluntarily and knowingly recognize, accept and assume the risk.