ENROLLMENT

BASIC INFO

PLEASE FILL IN ALL REQUIRED SECTIONS OR FORM WILL NOT SEND

FIRST AND LAST NAME *

GUARDIAN(S) NAME if applicant is under 18 years old.

RELATIONSHIP TO APPLICANT

DATE OF BIRTH: *

ARE YOU A FIRST RESPONDER? (FIRE, POLICE, MEDICAL)

Email Address *

Phone Number *

MAILING ADDRESS (INCLUDING TOWN/CITY) *

Have you ever studied martial arts before? *

Current rank in BJJ? Date of your last BJJ belt promotion?

How did you find out about GRIZZLY JIU JITSU?0 / 180

PERSONAL MEDICAL INFORMATION

(NOTE: ALL OF THE INFORMATION IN THIS SECTION WILL BE TREATED AS STRICTLY CONFIDENTIAL, AND WILL BE USED ONLY IN THE DETERMINATION OF THE APPLICANT'S FITNESS TO PARTICIPATE IN ACTIVITIES WITH GRIZZLY JIU JITSU AND IN CASE OF EMERGENCY.)

Are you allergic to any medications or drugs? (PLEASE LIST) *

Do you have any medical/physical conditions that an emergency medical technician or medical worker should know about (for example, recent surgery, diabetes, contact lenses, etc.) (IF YES, EXPLAIN) *0 / 180

Do you have any medical/physical conditions that may affect you or your ability to participate in class (for example, knee or back problems, neck injury)? (IF YES EXPLAIN) *0 / 180

Emergency contact NAME *

Phone Number *

Applicant's Signature: *

Date *

Parent or Guardian’s Signature

Date

WAIVER AND RELEASE OF LIABILITY

In consideration of being allowed to participate in any way in GRIZZLY JIU JITSU programs, related events and activities, the undersigned acknowledges, appreciates, and agrees that:

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. *

1.The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist, and, *

2.I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and, *

3.I willingly agree to comply with the stated and customary terms and conditions for participation. If however I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and, *

4.I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS GRIZZLY JIU JITSU, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event ("Releasees"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. *

5. Video Taping and Still Photography: I agree to be photographed and videotaped by GRIZZLY JIU JITSU without receiving compensation of any kind. I understand that this footage may be used for future promotions or social media posts which may be viewed by public and private sector audiences *

Applicant's Signature: *

Date *

(UNDER AGE 18 AT TIME OF REGISTRATION)This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify the Releasees from any and all liabilities incident to my minor child's involvement or participation in these programs as provided above. *

Parent or Guardian’s Signature

Date