MARYLAND SYSTEMA, LLC – General Waiver Form
I, the undersigned, acknowledge that I am applying for instruction in a martial art involving strenuous exercise and personal body contact. I understand that because of this there is always an inherent risk of injury that cannot be eliminated. Such injuries may include, but are not limited to, bruises, pulled muscles, dislocated joints and broken bones.
I understand that there are some unavoidable circumstances where these conditions may require special caution on my part to minimize danger to others or myself and I acknowledge that it is my responsibility to act accordingly.
In particular, I understand that some students could be infected with diseases like HIV/AIDS and Hepatitis that can be transmitted by exchange of blood or other bodily fluids and that I may be training with them.
I acknowledge that I have read and will follow proper procedures for dealing with injuries to myself and others that present opportunities for exposure to blood or body fluids.
As a condition to being admitted as a student, I assume the risk of all injuries and do hereby hold Maryland Systema, LLC, its instructors James Eglin and Michael Dorsey, and the training facility harmless from any and all liability due to injuries suffered by me or caused by third parties to me,
Arising out of activities involving Systema training, or any variation thereof, whether occurring on the premises of the studio or elsewhere, excepting on those claims, actions or damages caused by the gross negligence or intentional acts or omission of any of them.
I understand that Systema is an educational system. For the benefit of the education and training and for the safety of the other members, and myself I will strictly follow the rules of training as explained by the Instructor.
Along with mindful safe training on my part, I will also behave as a mature adult and will refrain from “horseplay”, pranks, and harassment toward other students regardless of intent. Should I break any of the rules, I understand that it is the decision of the Instructor whether or not I may continue training. I will abide by this decision.
Photographs or videos may be taken during the class for educational or promotional purposes. Unless I speak up or request not to be photographed/recorded on video beforehand, I agree to and hereby release my likeness for limited uses as explained by the instructor.
Blood-Borne Pathogen Policy
Generally, instructors and all persons training shall treat all exposed bodily fluids as if they are infected. The following measures will be observed at all times:
• If you have any open cuts or sores, you must clean them with a suitable antiseptic and cover them securely with a leakproof dressing before training.
• If a bleeding wound, even a minor one, occurs during training, the person bleeding shall immediately stop and leave the training area until the bleeding stops and the wound is securely covered.
Immediate measures shall be taken to stop the bleeding. If the person needs assistance, each person assisting shall wear a pair of latex gloves which are available in the first aid kit.
Hands shall be washed with soap and hot water immediately after gloves are removed. All used gloves, and bloody rags or dressings, will be placed in a leak proof plastic bag provided for that purpose, and disposed of carefully. Minor bloodstains should be treated with a disinfectant solution provided for this propose.
If there are major bloodstains, the clothing shall be removed as soon as practicable, placed into a leak-proof container and handled carefully until it can be laundered or disposed of.
• If you come into contact with the blood of another, you shall immediately stop training, leave the training area, and wash the exposed area thoroughly with soap and hot water before returning.
• If blood is present on the training surface, the training partner of the person bleeding should insure that no one inadvertently comes in contact with the blood. The blood should be cleaned up as soon as possible by wiping down the exposed surface with a disinfectant solution provided for that purpose.
Each person assisting in this task shall put on a pair of latex gloves and shall wash their hands with soap and hot water after the gloves are removed.
• You are reminded that you are responsible for not only your own health and safety, but the health and safety of others with whom you train.
If you know or suspect that you have any illness or disease which might infect others, refrain from training until you are not a risk to others.
Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), Maryland Systema is taking extra precautions with the care of every person associated with Maryland Systema.
Due to this event, I hereby agree to the following: I understand COVID-19 symptoms (fever, fatigue, dry cough, difficulty breathing) and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days. I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the past 30 days.
I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the past 30 days. I affirm that I, as well as all household members, have not traveled outside of the country, or to any city considered to be a “hot spot” for COVID-19 infections within the past 30 days.
I understand that Maryland Systema cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each person.
I have read, understand, and agree to the terms above.
Contact Information (Student) Name:
Emergency Contact Name:
Relationship to Student: