Waiver & Release of Liability Name of participant * (Name of child or adult signing up) First Name Last Name Gender * Male Female Date of Birth * MM DD YYYY Email * Phone * (###) ### #### Allergies? * Yes No If so please explain: Serious Health Conditions: * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Participating Minor's Parents Name: Email Address * Phone (###) ### #### Emergency Contact: * First Name Last Name Emergency Contact Relationship: * Emergency Contact Phone: * (###) ### #### Why do you want to train Jiu Jitsu? Child's performance in school / grades Competition Physical Fitness Mental Discipline Self Defense Other Medical and Media Waiver: * Medical and Media Waiver I hereby approve the minor's or my application for membership at Welcome to the Jungle LLC 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 Welcome to the Jungle LLC 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 Welcome to the Jungle LLC’s legal fees. I further grant Welcome to the Jungle LLC and the media, in any form, permission to publish/use photographs or videotape footage of my son/daughter/myself for any purpose relating to Welcome to the Jungle LLC and release Welcome to the Jungle LLC and any media of responsibility from the use of such photographs or footage. I have read and agree to the Medical and Media Waiver 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 Welcome to the Jungle LLC 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 Welcome to the Jungle LLC., 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 Welcome to the Jungle LLC classes or training at Welcome to the Jungle LLC. at any point in time. Jiu-Jitsu is a full contact activity. In participating in this activity at Welcome to the Jungle LLC., could potentially expose you to Covid-19. I understand that Welcome to the Jungle LLC. 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 Welcome to the Jungle LLC. 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 Welcome to the Jungle LLC. 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. I have read and agree to the Waiver of Liability Type Full Name For Waiver Confirmation * Thank you!
