STUDENT INFORMATION *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

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EMERGENCY CONTACT INFORMATION *

First Name

Last Name

Phone *

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I UNDERSTAND THERE WILL BE A SEPARATE FORM OF COMMUNICATION ABOUT PROCESSING MY CREDIT CARD PAYMENT

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THERE IS A 3.75% CREDIT CARD PROCESSING FEE

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No refunds after billing is complete. if you wish to cancel, please let us know 48 hours before your next billing cycle.

PHOTO/VIDEO PERMISSION *

I agree that from time to time, that Greenwich Jiu Jitsu Academy will take photos and videos of its participants during program activities and events for use in educational or promotional materials in print, multimedia or web form. Please check the correct box if you give or do not give consent.

Yes, I give consent to use photos/videos of myself

No, I do not give consent to use photos/videos of myself

WAIVER AND RELEASE OF LIABILITY *

Please check the box and sign and date that you agree to the following statement

In consideration of the Greenwich Jiu Jitsu Academy furnishing services and/or equipment to enable me to participate in Jiu Jitsu, Wrestling, and Self Defense training. I fully understand and acknowledge that the activities I undertake in connection with Jiu Jitsu, Wrestling, and Self Defense training have inherent risks, dangers and hazards, my participation in such activities may result in injury or illness including, but not limited to, bodily injury, bruises, disease, strains, fractures, partial and/or total paralysis, death or other ailments that could cause serious disability, these risks and dangers may be caused by the negligence of volunteers, the negligence of the participants, the negligence of others, accidents, the forces of nature or other causes. Risks and dangers may arise from foreseeable or unforeseeable causes including but not limited to, the instructors; decision making, the acts or omissions of other participants in the Jiu Jitsu, Wrestling, and Self Defense class and such other risks, hazards and dangers that are integral to the activities that take place in Jiu Jitsu, Wrestling, and Self Defense training and physical skills atmosphere; and by my participation in these activities and/or use of equipment. I hereby assume all risks and dangers and all responsibility for any losses and/or damages, whether caused in whole or in part by the negligence or other conduct of the participants, volunteers, instructors, or by any other person. I, on behalf of myself and my parent/guardian hereby voluntarily agree to release, waive, discharge, hold harmless, defend and indemnify The Greenwich Jiu Jitsu Academy, it’s instructors and members from any and all claims, actions or losses for bodily injury, property damage, property loss, wrongful death, loss of services or otherwise which may arise out of my use of equipment or my participation in any and all activities of this program/class. I specifically understand that I am releasing, discharging and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the participants, volunteers, instructors, or by any other persons. I have read the above waiver and release with my parent/guardian, and by signing below, I hereby agree to its terms. It is my intention to exempt and relieve The Greenwich Jiu Jitsu Academy and its instructors from liability for personal injury, property damage, property loss, or wrongful death caused by negligence or any other cause.

Name *

First Name

Last Name

Date *

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DD

YYYY