Waiver and Release of Liability

DNA Level C Boxing Club Membership Form Waiver and Release of Liability, Assumption of Risk & Parental Consent & Indemnity Agreement

Application Date:

Parent's Last Name:

First Name:

MI:

Child's Last Name:

Child's First Name:

MI:

Birth Date:

Age:

Address:

Apt #:

City:

State:

Zip:

Telephone #:

Cell:

Have you competed professionally in MMA, ultimate fighting, Wildman, toughman or similar competitions YesNo