Participantʻs Name *

First Name

Last Name

Participantʻs Date of Birth *

MM

DD

YYYY

Participantʻs Primary Family Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Parent/Guardian's Name *

First Name

Last Name

Primary Parent/Guardian's Phone *

(###)

###

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Secondary Parent/Guardian's Name

First Name

Last Name

Secondary Parent/Guardian's Phone

(###)

###

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Read each statement below and check the acknowledgement box in front. ALL Statements must be checked, read, understood, and acknowledged before participating. *

BY CHECKING THE ACKNOWLEDGEMENT BOX IN FRONT OF EACH STATEMENT, I ACKNOWLEDGE ON BEHALF OF MY MINOR THAT I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY ALONG WITH THE ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY THIS ACKNOWLEDGEMENT, AND HAVE DONE SO FREELY AND VOLUNTARILY WTHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND MY ACKNOWLEDGMENT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW. I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF HAWAII THAT THIS STATEMENT IS TRUE AND CORRECT.

I recognize and understand that martial arts training is a physical contact activity and that my participation might result in serious injury, including permanent disability or death, and severe social and economic loss.

I recognize and understand that such risk may be due to not only my own actions, but also the action, inaction or negligence of others, the regulations of participation, or the conditions of the premises, or of any of the equipment used.

I recognize that there may be other risks that are not known to me or to others or not reasonably foreseeable at this time.

I agree to inspect the facilities, equipment and pairings prior to participation. I will immediately inform an instructor if I believe that anything is unsafe or beyond my capability and refuse to participate.

I assume all of the foregoing risks and accept personal responsibility for any damages that may result from injury, permanent disability or death.

I enter martial arts training and/or competition entirely of my own free will and understand the importance of following the rules of training and competition.

I will follow all the rules and regulations of Waimea Brazilian Jiu Jitsu Program and agree to abide by the instructions given therein.

I certify that I am in good physical condition, and have no disease, injury or other condition that would impair my performance or physical and mental well-being during intense training practice and/or competition.

Grant permission in case of injury to have a doctor, nurse, athletic training or other emergency medical personnel provide me with medical assistance or treatment for such injury.

I Release, waive, discharge and covenant not to sue, The Waimea Brazilian Jiu Jitsu Program, its affiliated organizations and governing bodies, their officers, instructors and personnel, other members of the organizations, participants, supervisors, coaches, sponsoring organizations or their agents, and if applicable, owners and lessors and lessees of the premises from any and all liability to the undersigned, his or her heirs and next of kin for any and all claims, demands, losses and damages which may be sustained and suffered on account of injury, including death or damage to property, caused or alleged to be caused in whole or in part by the negligence of the realeasees or otherwise.