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395 Pleasant Valley Way
West Orange, NJ 07052

 

RELEASE, INDEMNIFICATION, AND HOLD HARMLESS AGREEMENT

WAIVER AND RELEASE OF LIABILITY AND AGREEMENT TO PARTICIPATE

(Please read before signing)

  1. Acknowledge and fully understand that I will be engaging in a contact sport/martial arts (Brazilian JIu Jitsu/Jiu Jitsu/Submission Wrestling/Grappling/Wrestling/Judo/ Martial Arts in General) that might result in serious injury, including permanent disability or death, and severe social and economic losses due to not only my own actions, inactions, or negligence, but also to the actions, inactions, or negligence of others, or conditions of the premises or of any equipment used.
     
  2. Further, I acknowledge that there may be other risks not known to me or not reasonably foreseeable at this time. These risks include, among other things: intense, stressful and strenuous exercises with body contact. I expressly consent to confront these known and unknown dangers and further agree, understand and recognize that these risks may result in serious injury or illness including but not limited to: bruises, bloody noses, broken bones, sprains, dislocations, heart attacks or other cardiovascular disease, or other serious injury resulting in death and/ or property damage
     
  3. I understand that martial arts can involve full contact fighting with throwing, wrestling, chokes and arm locks. Participants may use their maximum physical ability while participating. Learning new techniques involves risk as the person, the movement and the use of force are unfamiliar. Risk is an unavoidable and necessary part of the sport. As a member I have the right to ask questions about any risk and to refuse to participate. I understand and agree to assume these risks. In consideration of the privilege of using these facilities and receiving instructions I release from liability for accidents, damage, injury, or illness its owners, shareholders, employees. officers and instructors.
     
  4. Release, waive, discharge and covenant not to sue BeltQuest Jiu Jitsu (BeltQuest, LLC), together with their affiliated clubs, their respective administrators, directors, agents, coaches and other employees or volunteers of the organization, event officials, medical personnel, other participants, their parents, guardians, supervisors and coaches, sponsoring agencies, sponsors, advertisers, and if applicable, owners, lessors, and lessees of premises used to conduct the event,all of whom are hereinafter referred to as "release", from any and all claims, demands, losses, or damages on account of injury, including permanent disability and death and damage to property, caused or alleged to be caused in whole or in part by the negligence of the releasee or otherwise to the fullest extent permitted by law.
     
  5. I fully understand that any medical treatment provided to me as a response to injury will be of the first aid type only. I also fully understand that I am solely responsible for payment for any additional medical services performed as a result of my injury.
     
  6. The member is responsible for any personal property they bring to the martial school/club.

 

WAIVER AND RELEASE OF LIABILITY AND AGREEMENT TO PARTICIPATE

I HAVE READ THE ABOVE WARNING, WAIVER AND RELEASE, UNDERSTAND THAT I GIVE UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND KNOWING THIS, SIGN IT VOLUNTARILY. I AGREE TO PARTICIPATE KNOWING THE RISK AND CONDITIONS INVOLVED AND DO SO ENTIRELY OF MY OWN FREE WILL. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM

UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/GUARDIAN AS EVIDENCED BY THEIR SIGNATURE BELOW.

Dated: April 9, 2020

First Guest/Member's Name

First Name*

Middle Name

Last Name*

Phone*
First Guest/Member's Date of Birth*
First Guest/Member's Signature*
Second Guest/Member's Name

First Name*

Middle Name

Last Name*
Second Guest/Member's Date of Birth*
Third Guest/Member's Name

First Name*

Middle Name

Last Name*
Third Guest/Member's Date of Birth*
Fourth Guest/Member's Name

First Name*

Middle Name

Last Name*
Fourth Guest/Member's Date of Birth*
Fifth Guest/Member's Name

First Name*

Middle Name

Last Name*
Fifth Guest/Member's Date of Birth*
Sixth Guest/Member's Name

First Name*

Middle Name

Last Name*
Sixth Guest/Member's Date of Birth*
Seventh Guest/Member's Name

First Name*

Middle Name

Last Name*
Seventh Guest/Member's Date of Birth*
Eighth Guest/Member's Name

First Name*

Middle Name

Last Name*
Eighth Guest/Member's Date of Birth*
Ninth Guest/Member's Name

First Name*

Middle Name

Last Name*
Ninth Guest/Member's Date of Birth*
Tenth Guest/Member's Name

First Name*

Middle Name

Last Name*
Tenth Guest/Member's Date of Birth*
Guest/Member's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency contact: *

Relationship: *

Primary Phone: *
FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE (UNDER AGE 18 AT TIME OF REGISTRATION): This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release, as provided above, of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child's involvement or participation in these programs as provided above, even if arising from their negligence, to the fullest extent permitted by law. I have instructed the minor participant as to the above warnings and conditions and their ramifications.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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