17433 Alico Center Rd. Unit #3
Fort Myers, FL 33967
(239) 482-4300
Name: _____________________________
Parent’s Name: ______________________
Occupation: _________________________
DOB: _________ Age: _________
Street Address: ______________________
City: ___________________ State: ____
Zip: ____________
Phone: _____________________________
Email Address: ______________________
Emergency Contact: __________________
Emergency Number: __________________
How did you hear about the school? (check all that
apply) Internet Vehicle David Gallaher
Drive-by Referral ____________ Other________
What classes are you interested in? _______________
Do you have any experience in martial arts or Yoga?
Since martial arts and yoga have the potential to be dangerous, we require all participants to assume all
risks by signing this document.
1) I, ____________________________, or the participant’s parent(s) or legal guardian(s) understand and agree that
David Gallaher/Instructor or any of his assistants, volunteers, or employees shall not be liable for any damages
arising from personal injuries sustained by the student in or about the premises, resulting or arising out of the use
of the facility and equipment in the facility. This includes any and all claim for personal injury, property damages,
personal belongings or wrongful death resulting from or arising out of negligence of any other person present on
the said premises or directly outside of the said premises. This also covers any injuries that may occur during
exhibitions, demonstrations, workshops and competitions, inside or outside of the premises.
2) The acceptance of the student or party enrolling grants David Gallaher permission to use photographs and other
means to properly identify students in their group for reasons of promoting the Martial Arts to extend appreciation
to the masters of Jeet Kune Do/ Wing Chun/ Kali/Acro Yoga/Antigravity Yoga/Ashtanga Yoga, and to aid groups
involved in fighting crimes for a safer community. The acceptance of a 12 hour prior to cancelation policy
pertaining to Antigravity Aerial Yoga classes.
I have read this document and understand it is a release of all claims. I certify that all the above information is
correct to the best of my knowledge and I understand that falsifying information can be grounds for termination
from the school.
If you do not wish to receive physical assistance from your instructor, it is your responsibility to inform him/her.
_________________________________________ ______________________________
Signature (Student) Date
_________________________________________ ______________________________
Signature (Parent or Guardian) Date
________________________________________ ______________________________
David Gallaher Date