In this portion, please tell us a little about yourself.
First Name
Last Name
Home Phone
Cell-Phone
Email Address
Sex—Please choose an option—MaleFemale
Age
Birth Date
In the case of an emergency, who should we contact?
Contact Name
Phone Number
Relationship
Previous School
Instructors Name
Rank of Belt
Time Spent Training
City of school
State of School
Self DefenseWeight LossFitnessSportOther
DO YOU HAVE ANY MEDICAL CONDITIONS THAT WOULD AFFECT YOUR ABILITY TO TRAIN? —Please choose an option—YesNo
If yes, Please Explain
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
I agree that I have read and agree fully with the terms and conditions set forth above and my information is true and accurate to the best of my knowledge.
Please sign the field below by clicking/pressing and dragging.
