GBW New Customer Registration Form

1
Membership TypePlease select which option is relevant to yourself or your child
Tiny Champs (4ys-8yrs)
Juniors & Teens (9yrs-17yrs)
GB1 Fundamentals
GB2 Advancing
2
Full Name* This field is required.For under 18s please provide parent name and student name in brackets:- Parent (Child)
First Name
Last Name
3
Student's Date of Birth* This field is required.Please enter your date of birth. If you are a parent, please enter your child's date of birth.
Date
Year
Month
Day
4
Address* This field is required.Please provide your full address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Contact Number* This field is required.We will use this number to directly contact you about any school changes, class changes and to get in touch if we need to.
+44
Phone Number
6
E-mail* This field is required.You agree to subscribe to our emails. We will only send you school update & discounts.
example@example.com
7
Do you/ your child have any medical conditions, skin conditions/ allergies that we should be aware of?* This field is required.Please provide any details that we should be aware of relating to yours or your child's health.
Please type N/A if not applicable
8
What do you hope to achieve from starting your Brazilian Jiu-Jitsu journey?Choose one or more of the options below
Self Defense
Weight Loss
Learning a new skill
Making new friends
Discipline
9
Do you give us media consent to share photos and videos of you/ your child?* This field is required.We use social media accounts; Instagram and Facebook to share photos and videos of our classes. You may be in these shots, please select whether you give consent to us sharing these. Parents select whether you give consent for your under 18 to have their photos/ videos shared.
I do give consent to share photos & videos of myself/ child/ren
I do not give consent to share photos & videos of myself/ child/ren
I only consent to sharing my name
10
Member's Photo* This field is required.Please take a photo of yourself or the child* who is intending to train. *Parents:- this should be a clear photograph of your child. This photo will only be used internally for our own records.
11
Liability Waiver* This field is required.I hereby acknowledge and understand that Brazilian Jiu-Jitsu is a physical activity and learning self defense involves physical contact. Gracie Barra incorporated and/ or its staff are not to be held liable or responsible for any risks and/ or injuries as a result of training Brazilian Jiu-Jitsu. Please sign in the box to confirm you have read and agree to this statement. For under 18s this should be signed by their parent/ LEGAL guardian.
12
How did you hear about us?* This field is required.Please share how you heard about our Jiu-Jitsu school.
Please select an option
Please select an option
Instagram
Facebook
Website
Referral
Passing by
Other
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