Participant Name *

*To be completed by all persons over 16 years of age*

First Name

Last Name

Parent / Guardian Name *

*To be completed by parent or guardian of child participating in martial arts classes*

First Name

Last Name

Phone

(###)

###

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Emergency Contact Info *

First Name

Last Name

Phone *

(###)

###

####

What classes are you interested in?

Brazilian Jiujitsu

MMA

Wrestling

Other

DISCLAIMER

1. Recognize and understand that martial arts training is a physical contact activity and that my participation might result in serious injury, including permanent disability or death, and severe social and economic loss. 2. Recognize and understand 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. 3. Recognize that there may be other risks that are not known to me or to others or not reasonably foreseeable at this time. 4. Assume all of the foregoing risks and accept personal responsibility for any damages that may result from injury, permanent disability or death. 5. Enter martial arts training and/or competition entirely of my own free will and understand the importance of following the rules of training and competition. I agree to abide by the instructions given therein. 6. I certify that I am in good physical condition, and have no disease, injury or other condition that would impair my performance or physical and mental well-being during intense training practice and/or competition. 7.. Grant permission in case of injury to have a doctor, nurse, athletic training or other emergency medical personnel provide me with medical assistance or treatment for such injury. 9. Release, waive, discharge and covenant not to sue, Ronin Brazilian Jiu Jitsu & MMA, its owners, instructors and personnel, other members of the organizations, participants, supervisors or coaches. I HAVE READ THE ABOVE WARNING, WAIVER, RELEASE AND AGREEMENT TO PARTICIPATE. I UNDERSTAND ITS CONTENTS AND DO HEREBY CONFIRM IT VOLUNTARILY.

TICK TO CONFIRM

*Details of person agreeing to this form*

First Name

Last Name

Date

MM

DD

YYYY