Class full, sign up for wait-list

Instructor:

- Hind Essayegh, Empowerment Self-Defense Trainer.

Workshop Learning Goals:

Mental, verbal, and physical self-defense skills to avoid, interrupt, and respond to different types violence

Emotional regulation

Situational awareness

Assertiveness

De-escalation

Basic strikes and grab releases

Please confirm your participation by completing this form and signing the liability waiver below. If you are a minor under 18 years old, your parent or guardian should fill this form for you.

Name

First Name

Last Name

Email

Phone

(###)

###

####

Please indicate whether this registration is for an adult or a minor

Adult 18+

Minor 12+

Does the registrant have any accessibility needs?

Is there anything specific you are looking forward to getting out of this event?

For adults 18+: I understand that this activity includes physical movements as well as an opportunity for self-empowerment through self-defense. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. I affirm that I alone am responsible for my decision to participate in this training and that my participation is voluntary. I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against Hind Essayegh and the event organizers. I have carefully read and voluntarily sign this waiver.

I have carefully read and voluntarily sign this waiver

I am signing up for a minor ( see below)

For minors 12+ : My child will be participating in this self-defense workshop. I understand that this class includes some physical contact among students and between instructors and students. My child is in good health and is capable of participating in this workshop. If my child has any special physical needs or restrictions, I will notify the instructor(s) before the beginning of the workshop. I understand and agree to waive, release, and hold harmless Hind Essayegh and the event organizers from any claims or liabilities for injuries (physical or other), including those caused by any negligent act or omission of any of those mentioned, arising out of this workshop.

I consent to and understand all of the above

I am not signing up for a minor

Other

Accept Liability and Media waiver

In consideration of being permitted to utilize the facilities, services, and programs of the Muslim Family Center (or for my children to also participate) for any purpose, including, but not limited to observation or use of facilities or equipment, or participation in programs, the undersigned, for himself or herself and such participating children and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will, inspect and carefully consider such premises and facilities or the affiliated program. It is further warranted that such entry into the facility for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgment that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation by the undersigned and such children. The undersigned is aware of the different types of activities, equipment, and facilities offered by the organization, and is aware of the risks inherent in the participation in such activities and use of such equipment and facilities. In further consideration of being permitted to enter the facility for any purpose including, but not limited to observation or use of facilities or equipment, or participation in any program affiliated with the organization, the undersigned hereby agrees to the following: 1. The undersigned on his or her behalf and on behalf of such children, hereby releases, waives, discharges, and covenants not to sue the Muslim Family Center, its directors, officers, employees, and agents (hereinafter referred to as "releasees") from all liability to the undersigned or such children and all his personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefor on account of injury to the person or property or resulting in the death of the undersigned or such children whether caused by the negligence of the releasees or otherwise while the undersigned or such children is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the Muslim Family Center. 2. The undersigned hereby agrees to indemnify and save and hold harmless the releasees and each of them from any, loss, liability, damage, or cost they may incur due to the presence of the undersigned or such children in, upon or about the premises or in any way observing or using any facilities or equipment of the organization or participating in any program whether caused by the negligence of the releasees or otherwise. 3. The undersigned hereby assumes full responsibility for any risk of bodily injury, death, or property damage to the undersigned or such children due to negligence of releasees or otherwise while in, about, or upon the premises and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the Muslim Family Center. 4. The undersigned hereby gives permission to Muslim Family Center, to use photographs, voice recordings, or videos taken during the games and events associated with Muslim Family Center in any manner to help promote the activities as determined in the sole discretion of the Muslim Family Center. Such use could include publications, media releases, announcements, electronic or otherwise, and on websites or social media pages. The undersigned understands that neither they nor their child/ward will receive any compensation if such image appears in any of the manners listed above or any other manner that the Muslim Family Center deems appropriate. I agree that such image is the property of the Muslim Family Center. The undersigned further expressly agrees that the foregoing release waiver and indemnity agreement is intended to be as broad and inclusive as is permitted by the law of the State of Maryland and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. The undersigned has read and voluntarily signed the release and waiver of liability and indemnity agreement, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made.

I hereby confirm my understanding and acceptance of liability and media waiver