GRACIE JIU-JITSU BALANCE ACADEMY
WAIVER / RELEASE / ASSUMPTION OF RISK
{name} ____________________ {sign_date}____________ 10-Day Trial Ends: ______________
{dob} ____________ {phone} _________________ Email: ___________________________________
{address} ________________________________
Special Medical Conditions: __________________________________________________________________
How did you hear about us: __________________________ Do you have a profile on GracieU? Yes No
Emergency Contact: ___________________________ Cell Ph: ______________________________
Parent/Guardian Info (MINORS ONLY):
{name} ______________
Parent/Guardian BIRTHDATE (MINORS ONLY FOR GRACIE U ACCESS): MM/YY ___________
WAIVER / RELEASE / ASSUMPTION OF RISK
PLEASE READ CAREFULLY - THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS
Balance Martial Arts Inc. dba Gracie Jiu-Jitsu Balance Academy (GJJBA) and Gracie Jiu-Jitsu Peachtree City, endeavors to provide a safe environment and programs for you, your family, and guests. These programs, however, necessarily have a certain amount of risk associated with them. The purpose of this document is to be sure you understand those risks and to secure your agreement to assume these risks on behalf of yourself and any participating children for which you are legally responsible, and to ensure you are aware of and adhere to GJJBA’s safety and other policies.
By signing this Agreement you represent that you understand and agree to the following:
- I understand and have had explained to me that the martial art known as “Gracie Jiu-Jitsu” is taught using precautions to avoid any injuries. However, participation in the Gracie Jiu-Jitsu classes carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks range from minor injuries such as scratches, bruises, and sprains, to major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions, to catastrophic injuries including paralysis and death. Furthermore, I understand the practice of Gracie Jiu-Jitsu presents a risk of skin infections, communicable diseases, bacteria(s) and viruses, including, but not limited to, COVID-19.
- It is my responsibility prior to engaging or permitting any of my dependents to engage in any exercise program or other activity involving physical activity, to consult with my or my dependent's physician to determine whether I and/or my dependents are medically able to engage in the GBJJA program or activity. It is my responsibility to monitor my own condition and those of any dependents throughout any activity and, should any unusual symptoms occur, to cease participation and inform the staff of the symptoms.
- In the unlikely event an emergency should occur, I give permission to any GJJBA staff person to administer first aid in the event of an emergency and to summon 911 response units for any medical treatment needed for me and/or my dependents. I understand that the staff will try to telephone the emergency contact(s) listed above, but they not required to do so before action is taken. I agree that any medical expenses incurred by me or my dependents as a result of injury or illness at GJJBA will be my responsibility. I also understand and acknowledge that I am required to and will maintain appropriate medical insurance during the time I participate in any activities at GJJBA. For any minor child participating in these activities, I understand and acknowledge that I am responsible for monitoring and attending to my minor children, regardless of whether such children are participating in Gracie Jiu-Jitsu activities and training or not.
- I understand and have had explained to me that along with the possibility of personal injury, injury to property and other financial losses are also possible as a result of participation in activities at GJJBA, such as, but not limited to, possible loss of wages and the ability to earn such wages. With full knowledge of the aforementioned dangers, both to my person and to my property (current and future), and after having these dangers fully explained to myself and/or to my legal guardian, I nevertheless desire to participate in Gracie Jiu-Jitsu training and activities. Further, knowing and understanding these risks, I hereby agree to voluntarily assume these risks and to release and hold harmless all the persons or entities mentioned above who might otherwise be liable to me for damages. I understand that this waiver, release, and assumption of risk is forever binding on me, my heirs, assigns, executors, administrators and representatives.
I hereby certify and declare that I release and forever hold harmless and discharge from any liability GJJBA, Gracie Global, LLC d/b/a Gracie University, and each of their respective owners, members, managers, agents, stockholders, directors, officers, employees, volunteers, representatives, Rener Gracie, Ryron Gracie, any other members of the Gracie family (collectively “Gracie”) of and from all claims, demands, rights and causes of action of any nature whatsoever which may have or which may hereafter accrue to me, arising from and by reason of any and all bodily or personal injury, damage to property or other loss and any consequence thereof, whether known or unknown, seen or unforeseen, resulting from my participation in Gracie Jiu-Jitsu or any other activities at GJJBA, including and not limited to any negligence on the part of Gracie whether as a result of training or not.
I understand that GJJBA checks all its students with the national sex offender database (NSOPW.gov) for the safety of its students and I agree that such a check can be performed on me and authorize GJJBA to perform such a check. I understand that GJJBA reserves the right to refuse service to any individual who has been convicted of a sex crime.
I am also aware that for purposes of safety, security, and quality control there are surveillance cameras mounted throughout GJJBA. Furthermore, I understand and acknowledge that video recording or photographs may be taken of me and/or my minor child during classes/training or other Activities at GJJBA. I hereby grant GJJBA the unlimited use of my and my minor child’s likeness in any format photo, video, or other, for promotional advertisement or commercial use in any format known or yet to be developed in perpetuity, and I forfeit any form of payment therefore. It is further understood that I will not video record or photograph any classes/training without prior permission from an authorized representative of GJJBA.
My signature on this document is evidence that I know and understand and have had this document explained to me, that I fully understand the dangers that are inherent in the activities at GJJBA.
{name} ____________________ ______________ {sign_date}___________________
Printed Guardian {name} __________________ Guardian ______________________
(Guardian Signature required if student is less than 18 years old)
