Name of Participant *

Name of Person doing the FREE Trial

First Name

Last Name

Gender *

Male

Female

Date of Birth *

of participating child or adult

MM

DD

YYYY

Phone number *

(###)

###

####

Why do you want to train Jiu Jitsu? *

Child's performance in school / grades

Competition

Physical Fitness

Mental Discipline

Self Defense

Other

Have you trained before? If so please select current belt status *

I have not trained before

White Belt (kids)

Grey Belt

Yellow Belt

Orange Belt

Green Belt

White (adult)

Blue Belt

Purple Belt

Brown Belt

Black Belt

Please select the class(s) by age you will be attending for your free class. *

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

Pee Wee class (5-7yrs) 4:15 PM

Kids class (8-13yrs) 5:00 PM

Adult/Teens Fundamentals 6:00 PM

Adult Class All Levels 7:00 PM

Adult Class Mornings 7:00 AM

Adult Class Midday 11:30 AM

Open Mat Saturday 9:00 AM

Open Mat Sunday 10:00 AM

Free Trial Start Date *

MM

DD

YYYY

Emergency Contact: *

First Name

Last Name

Emergency Phone # *

(###)

###

####

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 *

Medical and Media Waiver I hereby approve the minor's or my application for membership at Ethos 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 Ethos 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 Ethos Jiu Jitsu’s legal fees. I further grant Ethos 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 Ethos Jiu Jitsu and release Ethos Jiu Jitsu and any media of responsibility from the use of such photographs or footage.

Confirmed

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 Ethos 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 Ethos 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 Ethos Jiu Jitsu Inc classes or training at Ethos Jiu Jitsu Inc. at any point in time. Jiu-Jitsu is a full contact activity. In participating in this activity at Ethos Jiu Jitsu Inc, could potentially expose you to Covid-19. I understand that Ethos 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 Ethos 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 Ethos 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.

Confirmed