waiver

Street Jitsu Justin

Waiver of Liability and Indemnity Agreement

THIS AGREEMENT MUST BE SIGNED BY ALL PERSONS WHO WISH TO PARTICIPATE IN ANY STREET JITSU CLASS, EVENT, OR ACTIVITY.

Form Name*

Date*

Date

Hour MinutesAM/PM Option

Select Gym*

Select Class that brought you to Street Jitsu*

First Name *

Student First Name

Last Name*

Student First Name

Participant Date of Birth*

Date

Student Sex:*

MaleFemale

Participant Address*

Street Address Line 2

Mobile Number*

Please enter a valid phone number.

Email:*

Home/Alt Phone:

Alt Email:

1. Does participant have any history of heart trouble?*

YesNo

2. Has participant ever experienced pain or tightness in their chest?*

YesNo

3. Has participant ever had a stroke?*

YesNo

4. Does participant have high or low blood pressure?*

YesNo

5. Does participant often suffer from severe dizziness?*

YesNo

6. Does participant have diabetes?*

YesNo

7. Is participant pregnant?*

YesNo

If you answer ‘Yes’ to any of the medical questions, it is recommended the participant obtain a physician’s release before utilizing the Academy’s classes and facilities.*

Participant AGREES

1st Emergency Contact*

Relation:*

2nd Emergency Contact

Relation:

Waiver & Agreement

This agreement is between RQS Inc. dba Street Jitsu & RD BJJ LLC dba Street Jitsu of Justin, hereafter referred to as “Street Jitsu” and the above-named participant or parent/guardian signing below if participant is a minor, hereafter referred to as “Participant”.

In consideration of being allowed to participate in any way in the classes, events, and/or activities, the above-named participant AGREES to the following:

1. Participant represents that he/she is in good physical condition and is able to participate in any classes, events or activities and are fully aware of the risks and hazards inherent with the participation in martial arts and in fitness activities, including physical injury or even death.*

Participant AGREES

2. Participant voluntarily elects to participate in said events or activities, knowing that the associated physical activity may be hazardous to them and their property.*

Participant AGREES

3. Participant VOLUNTARILY ASSUMES FULL RESPONSIBILITY FOR ANY PHYSICAL AND HEALTH RISKS, PROPERTY LOSS AND DAMAGE, OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by them, or loss or damage to property owned by them, as a result of participation in these activities. Certifies that they are at least 18 years of age. If under 18 years of age, the parent/guardian is equally aware of risks associated with participation in classes, events, and/or activities and is the below signed.*

Participant AGREES

4. Participant recognizes and understands that such risk may be due to not only my own actions, but also the action, inaction or negligence of others, the regulations of participation, or the conditions of the premises, or of any of the equipment used.*

Participant AGREES

5. Participant recognizes that there may be other risks that are not known to me or to others or not reasonably foreseeable at this time. Agree to inspect the facilities, equipment and pairings prior to participation.*

Participant AGREES

6. Participant will immediately inform an instructor if he/she believes that anything is unsafe or beyond my capability and refuse to participate.*

Participant AGREES

7. Participant will immediately inform an instructor if he/she believes that anything is unsafe or beyond my capability and refuse to participate.*

Participant AGREES

8. Participant accepts full responsibility for the use of, or participation in, any and all classes, services, equipment, demonstrations or events, whatsoever owned or operated by Street Jitsu, whether on-site or off-site and hereby releases and agrees to hold harmless, Street Jitsu, its owners, officers, directors, members, employees, representatives and agents from any and all loss, claim, injury, damage or liability sustained or incurred by the participant resulting there from. This release shall be binding upon the heirs, distributes, next of kin, executor and administrator of each of the undersigned.*

Participant AGREES

9. Participant grants permission in case of injury to have a doctor, nurse, athletic trainer or other emergency medical personnel provide me with medical assistance or treatment for such injury when incapacitated or for a minor in the absence of a parent/guardian.*

Participant AGREES

10. Participant understands that they may encounter the news media, video and film crews, or photographers hired by Street Jitsu for the purpose of taking promotional or publicity photographs, video or film and that there is a possibility that participants attending training or related activities will be photographed.*

Participant AGREES

11. Participant gives their consent to authorize Street Jitsu, or any entity or person authorized or designated by them the use and reproduction of any and all photographs, video or film taken of the person named as the subject of this agreement during Street Jitsu training or related activities and waive any right to royalties or other compensation arising from or related to the use of the photograph.*

Participant AGREES

12. Participant understands that all negative and positives, together with said prints, video or film are the property of the Street Jitsu or the entity or person authorized or designated by it, solely and completely and waives any rights to inspect or approve any photo, video or film taken during said training or related activities. Affirmatively releases and discharges Street Jitsu from responsibility for any distortion or manipulation, whether intentional or otherwise, of photos, video or film taken while a participant in Street Jitsu training or related activities.*

Participant AGREES

13. Participant hereby agrees to abide by all rules and regulations of Street Jitsu, which may be posted or issued verbally, as amended from time to time.*

Participant AGREES

In signing this Agreement, the undersigned hereby acknowledges that he/she is at least 18 YEARS OF AGE, and represents that he/she has read and fully understands the waiver and agreement; that I have fully consented to such waiver and agreement and expressly give myself and/or this minor permission to participate in Street Jitsu training or related activities. Furthermore, I certify that this application is complete, correct, and true to the best of my knowledge and sign it voluntarily.

Participant or Parent/Guardian Signature*

Print First Name*

Print Last Name*

Date*

Hour MinutesAM/PM Option

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Medical Information