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Paragon Brazilian Jiu Jitsu Kimberling City Waiver Disclaimer

Student Name:  {name}               Phone:  {phone}               D.O.B.:  {dob}

Address:  {address}

Emergency Contact:  {contact_name}                Emergency Contact Phone:  {contact_phone}

Emergency Contact Relationship:  {contact_relation}

Read Carefully Before Signing – Acknowledgement, Waiver & Release from Liability

I acknowledge that Brazilian Jiu Jitsu & Mixed Martial Arts is an extreme test of my physical and mental limits and carries with it the risk of serious injury and/or death and property loss. I hereby assume the risks of participating in this martial arts institute. I certify that I am physically fit, have sufficient mentality for participation in this martial arts school, and have not been advised otherwise by a medical person.

I hereby take action for myself, my executors, administrators, heirs, next of kin, successors and assigns as follows; waive, release, discharge and agree not to sue, from any and all liability for my personal injuries, disabilities, personal theft, or action of any kind which may hereafter accrue to me as a result of my participation in this martial arts institute.

I also hold harmless from any and all liabilities or claims made by other individuals or entities as a result of my actions during my practices, tournaments, etc.; the following: instructor Joseph Harris, and/or instructors, sponsors, directors, event producers, or event volunteers.

I grant permission to Paragon Brazilian Jiu-Jitsu Association, and its agents, employees or assigns, the irrevocable right to use the photographs taken and provided by me as identified below for use in any publication such as advertising, direct mail, brochures, newsletters, and magazines, and to use the photographs on display boards, and to use such photographs in electronic versions of the same publications or on websites or other electronic forms or media. I also grant permission to paragon, its agents, employees or assigns to offer the identified photographs for use or distribution in other publications, electronic or otherwise, without notifying me.

Name of member or guardian signing the document:   

Date:  {sign_date}