Your Information

    In this portion, please tell us a little about yourself.

    First Name

    Last Name

    Address

    Home Phone

    Cell-Phone

    Email Address

    Additional Information

    Sex

    Age

    Birth Date

    Emergency Contact

    In the case of an emergency, who should we contact?

    Contact Name

    Phone Number

    Relationship

    Previous Training

    Previous School

    Instructors Name

    Rank of Belt

    Time Spent Training

    City of school

    State of School

    What's your reason for training?

    Self DefenseWeight LossFitnessSportOther

    DO YOU HAVE ANY MEDICAL CONDITIONS THAT WOULD AFFECT YOUR ABILITY TO TRAIN?

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    Signature

    Name of Student/Parent/Guardian

    Today's date

    Name of Student

    BY COMPLETING THIS FORM YOU AFFIRM THAT ALL THE INFORMATION ABOVE IS TRUE AND ACCURATE. YOU AGREE TO THE LIABILITY WAIVER FORM SET FORTH ABOVE FROM TRIUMPH BJJ, LLC AND UNDERSTAND THAT THERE MAY BE RISKS ASSOCIATED WITH ANY SPORT AND AGREE TO THE TERMS SET ABOVE. THIS IS A BINDING AGREEMENT BETWEEN YOU AND TRIUMPH BJJ, LLC

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