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 view the classes by age that you will be attending. *

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

Kids 1 class 8-11 years old

Kids 2 class 12-14 years old

Kids 3 class 15-18 years old

Adults class

Free Trial Start Date *

MM

DD

YYYY

Emergency Contact: *

First Name

Last Name

Emergency Phone # *

(###)

###

####

Allergies *

yes

no

Checkbox

Please check any that apply to ensure appropriate support and accommodations:

Autism Spectrum Disorder (ASD)

Attention Deficit/Hyperactivity Disorder (ADHD)

Dyslexia

Dyscalculia

Dysgraphia

Auditory Processing Disorder

Visual Processing Disorder

Executive Functioning Challenges

Sensory Processing Differences

Intellectual Disability

Other

Prefer not to disclose

Medical and Media Waiver: I hereby approve the minor's or my application for membership at Boyle Heights 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 Boyle Heights 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 Boyle Heights Jiu Jitsu’s legal fees. I further grant Boyle Heights 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 Boyle Heights Jiu Jitsu and release Boyle Heights 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 Boyle Heights Jiu Jitsu. 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 Boyle Heights Jiu Jitsu, its 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 Boyle Heights Jiu Jitsu classes or training at Boyle Heights Jiu Jitsu at any point in time. Jiu-Jitsu is a full contact activity. In participating in this activity at Boyle Heights Jiu Jitsu, could potentially expose you to Covid-19. I understand that Boyle Heights Jiu Jitsu 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 Boyle Heights Jiu Jitsu 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 Boyle Heights Jiu Jitsu 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.