Complete Your Registration – Pathway Jiu Jitsu

1Student Information

2Waiver

How many memberships have you purchased? *

Member #1

Member Information

Name *

First

Last

Date of Birth *//

Email (parent/guardian if member is less than 18 years of age) *

Confirm Email

Phone (parent/guardian if member is less than 18 years of age) *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Membership *

Health Conditions/Concerns

Member #2

Name *

First

Last

Date of Birth *//

Email (parent/guardian if member is less than 18 years of age) *

Confirm Email

Phone (parent/guardian if member is less than 18 years of age) *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Membership *

Health Conditions/Concerns

Member #3

Name *

First

Last

Date of Birth *//

Email (parent/guardian if member is less than 18 years of age) *

Confirm Email

Phone (parent/guardian if member is less than 18 years of age) *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Membership *

Health Conditions/Concerns

Member #4

Name *

First

Last

Date of Birth *//

Email (parent/guardian if member is less than 18 years of age) *

Confirm Email

Phone (parent/guardian if member is less than 18 years of age) *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Membership *

Health Conditions/Concerns

Today's Date *//

“The Participant” refers to the individual(s) completing this form. All individuals 18 years of age or older must complete this form. A parent/guardian must complete this form on behalf of individuals less than 18 years of age. *

Number of individuals (18+) completing this form: *

Name *

First

Last

Name (Registrant 1) *

First

Last

Name (Registrant 2) *

First

Last

Name (Registrant 3) *

First

Last

Name (Registrant 4) *

First

Last

Participation in any activity at Pathway Jiu Jitsu including but not limited to practices, sparring, competitions, and observing such events, or any activity undertaken with Pathway Jiu Jitsu such as tournaments and mixed martial arts bouts signifies consent to be bound by the conditions of this agreement.

THE PARTICIPANT UNDERSTANDS AND ACKNOWLEDGES that training at Pathway Jiu Jitsu involves physical contact and that signing this agreement signifies consent to such contact. In addition, the Participant understands that martial arts training includes risk of bodily injury, paralysis, concussion, soreness, bleeding, disfiguration, damage to eyes and teeth, and death, and assumes all responsibility for such hazards. THE PARTICIPANT HEREBY KNOWINGLY AND FREELY ASSUMES ALL SUCH RISKS including risks associated with travel to and from Pathway Jiu Jitsu practices, events, and competitions.

Confirm *

THE PARTICIPANT AGREES TO HOLD HARMLESS AND FOREVER RELEASE, WAIVE, AND DISCHARGE PATHWAY JIU JITSU and its owners Tim Hickey and Ryan Hickey, as well as coaches, volunteers, and other members, from all claims, suits, complaints, demands, obligations, liabilities, and/or any actions that he/she/they may have due to personal injury, bodily harm, death, or damage to and loss of property suffered during any activity at or with Pathway Jiu Jitsu.

Confirm *

THE PARTICIPANT WAIVES ALL CLAIMS DUE TO INJURY, DEATH, AND LOSS OR DESTRUCTION OF PROPERTY obtained on the premises of Pathway Jiu Jitsu or through participation in any Pathway Jiu Jitsu activities, whether caused by active or passive negligence, fault, failure, or otherwise.

Confirm *

THE PARTICIPANT AGREES TO BE BOUND BY THE RULES AND REGULATIONS OF PATHWAY JIU JITSU and understands that such rules, in addition to any protective equipment or gear, exist to protect participants and eliminate as much risk as possible but in no way constitute a guarantee of safety or well-being.

Confirm *

THE PARTICIPANT UNDERSTANDS AND AGREES TO THE USE OF ANY AND ALL RECORDINGS TAKEN AT THE SCHOOL, such as pictures and videos, for promotional purposes by Pathway Jiu Jitsu. The Participant acknowledges that Pathway Jiu Jitsu retains sole ownership of all pictures and videos recorded on its premises.

Confirm *

I acknowledge that I have read and understood this agreement, that I have completed it freely and voluntarily, and that it is to be binding upon my heirs, executors, administrators, representatives, and myself.

Initials *

Initials (Registrant 1) *

Initials (Registrant 2) *

Initials (Registrant 1) *

Initials (Registrant 2) *

Initials (Registrant 3) *

Initials (Registrant 1) *

Initials (Registrant 2) *

Initials (Registrant 3) *

Initials (Registrant 4) *