Digital Signature Form

Name

Date of Birth

Address

Phone

1. Definitions “Applicant” means the individual who signs this waiver and indemnity, declaring that he/she understands and agrees to the conditions contained therein, and includes the individual’s guardian if the individual is under 18 years of age. “Providers” means the staff, instructors(including students who have been given charge of instructing a class or individual), and the venue providers of Legacy Brazilian Jiu Jitsu. 2. Exclusion of Applicant I have not at any time been excluded from participating in martial arts by a medical practitioner or any other person or entity, including a martial arts club or organization. 3. Medical Conditions I have not at any time suffered from any blackout, seizure, convulsion , fainting or dizzy spells, and am not presently receiving treatment for any illness, disorder or injury which would render it unsafe for me to take part in martial arts. I have advised the provider of any health problems, physical impairments, injuries or medical conditions that otherwise affect me. 4. Authority for First Aid and Medical Treatment I authorize the providers to give me first aid in the event of an injury, and /or to arrange for me to be transported to hospital for medical treatment. 5. Acceptance of risk I understand that martial arts is dangerous and agree that my participation is entirely at my own risk. I understand that I must abide by the rules if Legacy Brazilian Jiu Jitsu and any instructions provided to me by my instructor(s) at Legacy Brazilian Jiu Jitsu. 6. Video Release I understand that I may be photographed or video taped and consent to use these photographs and/or video recordings for Legacy Brazilian Jiu Jitsu advertising, publicity, commercial or other business purposes. I hereby release the providers and their agents from all claims of every kind on account of such use. 7. Waiver and Indemnity I and any other person in relation to myself hereby absolve and indemnify the providers and all of their agents, employees and others receiving instruction from the providers(collectively, the “Indemnified”) from all liability howsoever arising for injury, loss or damage(including but not limited to my person, property and personal belongings) however caused, including by the negligence of the indemnified, arising out of or in connection with the provision of instruction or related services or in any way caused by, or arising out of any activity carried on by the indemnified.

Your Signature
Parent/Guardian Digital Signature

Clear

Signed Date

Emergency Contact

Emergency Contact Phone