Name *

Name of participant required

First Name

Last Name

Date of Birth *

Day/Month/Year

MM

DD

YYYY

Phone *

Parent number if participant is a minor

(###)

###

####

Allergies? *

Yes

No

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency contact *

First Name

Last Name

Medical and Media Waiver *

Medical and Media Waiver I hereby approve the minor's or my application for membership at La Union Jiu Jitsu LLC 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 La Union Jiu Jitsu LLC 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 La Union Jiu Jitsu LLC’s legal fees. I further grant La Union Jiu Jitsu LLC and the media, in any form, permission to publish/use photographs or videotape footage of my son/daughter/myself for any purpose relating to La Union Jiu Jitsu LLC and release La Union Jiu Jitsu LLC 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 HAVE READ AND AGREE TO THE FOLLOWING WAIVER OF PARTICIPATION. 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 La Union Jiu Jitsu LLC 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 La Union Jiu Jitsu LLC., 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 La Union Jiu Jitsu LLC classes or training at La Union Jiu Jitsu LLC. at any point in time. Jiu-Jitsu is a full contact activity. In participating in this activity at La Union Jiu Jitsu LLC., could potentially expose you to Covid-19. I understand that La Union Jiu Jitsu LLC. 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 La Union Jiu Jitsu LLC. 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 La Union Jiu Jitsu LLC. 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