Smooth Jiu Jitsu Academy Member Sign Up

PLEASE READ CAREFULLY – THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS

I {name} or legal guardian of the aforementioned hereby agree and acknowledge:

1. I have been advised that the martial arts known as "Jiu-Jitsu" and "Muay Thai" is taught using precautions to avoid any injuries. However, participation in the  Jiu-Jitsu and Muay Thai classes carries with it certain inherent risks and dangers 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.
2. The practice of Jiu­Jitsu and Muay Thai presents a risk of skin infections, MRSA, transmittable diseases, bacteria(s) and viruses.
3. I shall not attend Jiu-Jitsu or Muay Thai classes if I am sick, including but not limited to skin infections, MRSA, transmittable diseases, bacteria(s) and viruses.
4. Along with the possibility of personal injury, injury to property is also possible, including but not limited to, possible loss of wages and the ability to earn such wages.
5. I acknowledge that I have consulted with a Doctor and I have no health problems that would preclude me from full and safe participation in Jiu-Jitsu and Muay Thai.
6. With full knowledge and understanding of the aforementioned risks, both to myself and to my property, and after having these dangers fully explained to myself and/or to my legal guardian. I nevertheless desire to participate in Jiu-Jitsu and Muay Thai training and activities. I consent to my child or person whom which I am the guardian to participate in jiu jitsu and muay Thai training and Activities.
7. Due to the nature of the activities conducted in Jiu Jitsu and Muay Thai classes, it would be unreasonable for Stephen Reeks (d.b.a. Smooth Jiu Jitsu Academy)  and/or the respective owners, directors and shareholders, agents and employees to be in any way responsible for my injury (or death) and to the full extent of the law I hereby waive my legal rights of action against and fully release the company for loss, damages, injury or death however arising out of or in relation to my participation in the activities conducted or organised by the company including, without limitation, liability for any negligent or tortious act or omission, breach of duty, breach of contract or breach of statutory duty on the part of the company, its office bearers, directors, employees or agents.
8. I have and will maintain appropriate medical insurance during classes/training. I authorize any emergency first aid, CPR, AEDs, medication, medical treatment, and/or emergency transportation and I assume all costs involved in such treatment.
9. I understand that Smooth Jiu Jitsu Academy reserves the right to refuse service to any individual who has been convicted of a crime.
10. I will not video record or photograph any classes/training without prior permission from Smooth Jiu Jitsu Academy.
11. I am also aware that for purposes of safety, security and quality control there are surveillance cameras mounted throughout Smooth Jiu Jitsu Academy. Furthermore, I understand and acknowledge that video recording or photographs may be taken of me during classes/training. I hereby grant  Stephen Reeks (d.b.a. Smooth Jiu Jitsu Academy) the unlimited use of my 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.
12. I agree that if any term of this agreement is to any extent illegal, otherwise invalid, or incapable of being enforced, all other terms shall remain in full force and effect.

I understand that this agreement and the student enrollment agreement supersede any and all previous oral or written agreements with regards to the practice of Jiu-Jitsu and Muay Thai. {sign_date}

ACTIVITY SAFETY QUESTIONNAIRE:

Please answer the following questions about your physical condition as best you can, so that we have an understanding of your current health and fitness to ensure you can participate in our programs in a safe way.                                                                                                                                 

Have you ever had, or do you currently have?

1. High blood pressure or high cholesterol?  YES / NO    
2. A heart condition / stroke / chest pain? A family history of heart disease, stroke or high cholesterol? YES / NO
3. Stomach ulcer / hernia / gout / liver or kidney disease? YES / NO
4. Epilepsy / diabetes / rheumatic fever?  YES / NO
5. Breathing difficulties or asthma? YES / NO
6. Arthritis / back pain / muscular pain or cramps? YES / NO
7. Any major injuries, or major surgeries? YES / NO
8. Are you on any prescribed medications?  YES / NO
9. Have you recently been in hospital? YES / NO
10. Do you have, or have you had any infectious diseases? YES / NO
11. Have you sought medical advice before commencing at Smooth Jiu Jitsu Academy - Smooth Muay Thai ?                YES / NO

If you answered YES to any of the questions above, please advise the instructor and explain here: