Name of Participant *

First Name

Last Name

Date of birth *

Birthday

MM

DD

YYYY

Phone *

(###)

###

####

Why do you want to train Jiu Jitsu? *

Child's performance in school / grades

Competition

Physical Fitness

Mental Discipline

Self Defense

Other

Please select the Age Group *

In order to keep everyone safe, please chose by age accordingly.

Pee Wee (5-7y)

Kids (8-12y)

Teens (13-17y)

Adults

Free Trial Start Date *

MM

DD

YYYY

Have you trained before? *

I did Jiu-Jitsu before

I did Wrestling before

I was in a grappling club before

I did Judo before

I never did any grappling before

Emergency Contact: *

First Name

Last Name

Emergency Phone # *

(###)

###

####

Allergies *

yes

no

Medical and Media Waiver: I hereby approve the minor's or my application for membership at ELA Jiu Jitsu and give my consent to I or the minor being given a physical examination or treatment by a physician or hospital in case of a medical emergency. I further agree to me or the minor taking part in the club’s various athletic, cultural and social activities and will not hold the members of the board, staff, leaders or volunteers responsible or liable in any way for harm or injury which may occur while participating in the same. It is agreed that the parent or guardian will not hold ELA Jiu Jitsu responsible for the welfare or whereabouts of the member. Professional supervision will be provided to children inside our facility only. If the Parent or Guardian does file a complaint against the Club the Parent or Guardian agrees to pay for ELA Jiu Jitsu’s legal fees. I further grant ELA Jiu Jitsu and the media, in any form, permission to publish/use photographs or videotape footage of my son/daughter/myself for any purpose relating to ELA Jiu Jitsu and release ELA Jiu Jitsu and any media of responsibility from the use of such photographs or footage. *

I HAVE READ AND AGREE TO THE MEDICAL AND MEDIA WAIVER

Confirmation of Waiver of Liability: I hereby assume full responsibility and liability for all damages, injuries and losses that I or my child may sustain or incur while participating in or watching during my entire tenure as a trial member or student of East LA Jiu Jitsu Inc. I realize that serious injury is common place in martial arts participation such as the one I am hereby entering and that death is a possibility. I also realize that if I or my child are injured, I or my child might be disfigured, disabled and/or rendered unable to work again. By entering into this trial and/or membership I agree to and fully accept and assume liability for any and all injuries that I or my child may incur expressly give up and waive any and all claims that I or anyone acting on my behalf or through me might have against East LA Jiu Jitsu Inc., it's board members, the promoters, operators, sponsors, officials, participants, non-participants, or volunteers for any injury regardless of its nature, effect or affect on me as a result of mine or my child's participation and/or presence at East LA Jiu Jitsu Inc classes or training at East LA Jiu Jitsu Inc. at any point in time. Jiu-Jitsu is a full contact activity. In participating in this activity at East LA Jiu Jitsu Inc, could potentially expose you to Covid-19. I understand that East LA Jiu Jitsu Inc. cannot be held liable for any exposure to the COVID-19 virus. Symptoms of COVID-19 include: Fever, Fatigue, Dry Cough, Difficulty Breathing. I agree to the following: I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days. I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the past 14 days. I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the past 14 days. I authorize, and agree to hold harmless, whatever medical personnel that may be present at the East LA Jiu Jitsu Inc. to take any action necessary, should I become injured. I represent that I and or my child are in good health; that I and or my child are not presently, nor will I or my child participate while under the influence of any drug or medication; that no one affiliated with East LA Jiu Jitsu Inc. has encouraged me to enter or made any representations regarding mine or my child's fitness or ability to participate; that I have read and understood every provision of this release; and that I am legally competent to and freely enter into this waiver, release and assumption of risk agreement. In case of minors under 18 years old. Furthermore, if the competitor is a minor I, hereby certify that I am parent and/or legal guardian of the above named minor who has been given my express permission to participate in the trial or membership for which we are registering. And, that I have read and understood every provision of the release of liability and that I am legally competent to and freely enter into this release of liability and assume all risk on behalf of the minor (participant) named herein and any and all successors, assigns or any other representative acting upon the minor's behalf. *

I HAVE READ AND AGREE TO THE WAIVER OF LIABILITY.