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Spring Mount Jiu-Jitsu, LLC
Enrollment Form

ASSUMPTION OF RISK, GENERAL RELEASE AND WAIVER OF LIABILITY

I am aware that during martial arts training or other activities in which I am participating or plan to participate under the sponsorship or arrangement of Spring Mount Jui-Jitsu, LLC. d/b/a Precision Jiu-Jitsu Spring Mount and any successor or affiliated entity thereof (hereafter, "Spring Mount"), certain risks and dangers may exist. I fully understand and acknowledge that:

(a) there are risks, hazards and dangers associated with participation in martial arts activities and instructions which could result in bodily injury, partial and/or total disability, paralysis and, possibly, death;

(b) the social and economic losses and/or damages which could result from such risks, hazards and dangers described above, could be severe;

(c) such risks, hazards and dangers may be caused by my action, inaction or negligence, or the action, inaction or negligence of others, including, but not limited to,SPpreincgisMiounn,tall or any of its owners, directors, officers, members, managers, instructors, independent contractors, representatives, agents, employees, volunteers, independent contractors, vendors, employees, students/members and/or landlord (“Releasees”); and

(d) there may be other risks not known to me or which are not reasonably foreseeable at this time.

I expressly accept and assume any and all risks, hazards and dangers and responsibility for any and all losses and/or damages following any such injury, damage, disability, paralysis or death, however caused, and whether caused in whole or in part by the actual or alleged negligence of the Releasees while participating in this activity. 

I FURTHER RECOGNIZE THAT NO REPRESENTATIONS OR GUARANTEES ARE BEING MADE TO ME BY PSRPERCINIGSIMOONUTNRTAJIUN-IJNITGSUC, ELLNCTER AS TO MY OWN PROFICIENCIES, LEVELS OF ATTAINMENT OR MY ABILITIES TO ENGAGE IN SIMILAR ACTIVITIES OR REAL LIFE SITUATIONS OF DANGER OR PERIL WITHOUT SUFFERING INJURY IN THE FUTURE.  

In consideration of the right to participate in any activities herein, I have and hereby agree to indemnify, defend and hold harmless the Releasees from all actions, losses, causes of action, demands, damages, suits and any and all claims, demands and liabilities whatsoever, both in law and equity, against Releasees which I now have or may acquire arising out of or in connection with my participation in or returning from any activity offered, arranged, affiliated or sponsored by the SPprreincgisMionun.t.I further agree to use prudent safety rules as set forth by Spring Mount.  

I, FOR MYSELF, MY SPOUSE OR CIVIL PARTNER, MY PERSONAL REPRESENTATIVE(S), ASSIGNS, EXECUTORS, ADMINISTRATOR(S), HEIR(S), NEXT OF KIN AND ANY PERSON/ENTITY ON MY BEHALF (“Releasors”) HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE SPprericnigsiMoonunt or any Releasees for any and all actions, losses, causes of action, demands, damages, suits and any and all claims, demands and liabilities whatsoever, both in law and equity, whether known or unknown, including, but not limited to, death, damage to property or personal injury, arising out of, relating to, in connection with or actually or allegedly caused by, in whole or in part, the actual or alleged negligence of the Releasees, my signing this document or participation in and returning from any activities, including, but not limited to, any instruction, exercises, training, special or limited time programs, tournaments, classes, or other offerings provided, arranged, sponsored or given by the Releasees or otherwise. 

I HAVE READ THIS ASSUMPTION OF RISK, GENERAL RELEASE, AND WAIVER OF LIABILITY, AND FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WTHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW. I AFFIRM THAT I AM AT LEAST EIGHTEEN (18) YEARS OF AGE, OR, IF I AM UNDER EIGHTEEN (18) YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/GUARDIAN AS EVIDENCED BY HIS/HER SIGNATURE BELOW.  

I further expressly agree that the foregoing provisions are intended to be as broad and inclusive as permitted by the laws of the Commonwealth of Pennsylvania, and that if any portion of any provision is held to be invalid, it is agreed that the remaining provisions shall continue in full legal force and effect. 

The terms hereof shall bind my heirs, executors, personal representatives, administrators, assigns any individual or entity purporting to act on my behalf, and shall serve as an assumption of risk, general release and waiver of liability for all members of my family, including any minor children, participating in such activity.

Today's Date: December 13, 2018

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Date Started:

Referred by:

Occupation:

Medical Information (Allergies & Other):
Chose the appropriate line:*

If aware, describe:

(If necessary, please attach a report from your primary care physician or treating medical practitioner.) 

By my signature below, I hereby certify that the information provided herein (or attached hereto) is complete and correct and thatSPpriencgiMsiountmay reasonably rely on such information for purposes of my participation in and returning from any activities offered. 

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Date Started:

Referred by:

Occupation:

Medical Information (Allergies & Other):
Chose the appropriate line:*

If aware, describe:

(If necessary, please attach a report from your primary care physician or treating medical practitioner.) 

By my signature below, I hereby certify that the information provided herein (or attached hereto) is complete and correct and thatSPpriencgiMsiountmay reasonably rely on such information for purposes of my participation in and returning from any activities offered. 

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Date Started:

Referred by:

Occupation:

Medical Information (Allergies & Other):
Chose the appropriate line:*

If aware, describe:

(If necessary, please attach a report from your primary care physician or treating medical practitioner.) 

By my signature below, I hereby certify that the information provided herein (or attached hereto) is complete and correct and thatSPpriencgiMsiountmay reasonably rely on such information for purposes of my participation in and returning from any activities offered. 

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Date Started:

Referred by:

Occupation:

Medical Information (Allergies & Other):
Chose the appropriate line:*

If aware, describe:

(If necessary, please attach a report from your primary care physician or treating medical practitioner.) 

By my signature below, I hereby certify that the information provided herein (or attached hereto) is complete and correct and thatSPpriencgiMsiountmay reasonably rely on such information for purposes of my participation in and returning from any activities offered. 

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Date Started:

Referred by:

Occupation:

Medical Information (Allergies & Other):
Chose the appropriate line:*

If aware, describe:

(If necessary, please attach a report from your primary care physician or treating medical practitioner.) 

By my signature below, I hereby certify that the information provided herein (or attached hereto) is complete and correct and thatSPpriencgiMsiountmay reasonably rely on such information for purposes of my participation in and returning from any activities offered. 

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Date Started:

Referred by:

Occupation:

Medical Information (Allergies & Other):
Chose the appropriate line:*

If aware, describe:

(If necessary, please attach a report from your primary care physician or treating medical practitioner.) 

By my signature below, I hereby certify that the information provided herein (or attached hereto) is complete and correct and thatSPpriencgiMsiountmay reasonably rely on such information for purposes of my participation in and returning from any activities offered. 

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Date Started:

Referred by:

Occupation:

Medical Information (Allergies & Other):
Chose the appropriate line:*

If aware, describe:

(If necessary, please attach a report from your primary care physician or treating medical practitioner.) 

By my signature below, I hereby certify that the information provided herein (or attached hereto) is complete and correct and thatSPpriencgiMsiountmay reasonably rely on such information for purposes of my participation in and returning from any activities offered. 

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Date Started:

Referred by:

Occupation:

Medical Information (Allergies & Other):
Chose the appropriate line:*

If aware, describe:

(If necessary, please attach a report from your primary care physician or treating medical practitioner.) 

By my signature below, I hereby certify that the information provided herein (or attached hereto) is complete and correct and thatSPpriencgiMsiountmay reasonably rely on such information for purposes of my participation in and returning from any activities offered. 

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Date Started:

Referred by:

Occupation:

Medical Information (Allergies & Other):
Chose the appropriate line:*

If aware, describe:

(If necessary, please attach a report from your primary care physician or treating medical practitioner.) 

By my signature below, I hereby certify that the information provided herein (or attached hereto) is complete and correct and thatSPpriencgiMsiountmay reasonably rely on such information for purposes of my participation in and returning from any activities offered. 

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Date Started:

Referred by:

Occupation:

Medical Information (Allergies & Other):
Chose the appropriate line:*

If aware, describe:

(If necessary, please attach a report from your primary care physician or treating medical practitioner.) 

By my signature below, I hereby certify that the information provided herein (or attached hereto) is complete and correct and thatSPpriencgiMsiountmay reasonably rely on such information for purposes of my participation in and returning from any activities offered. 

Participant'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's Name*

Emergency Contact's Phone Number*
FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE (UNDER AGE 18 AT THE TIME OF REGISTRATION) This is to certify that I am the parent/guardian with legal responsibility for the above participant, and I do hereby consent and agree to the terms and conditions of the Assumption Of Risk, General Release And Waiver Of Liability, as provided above, and I, for myself, my spouse or civil partner, heirs, assigns, next of kin and any individual or entity purporting to act on my behalf, do hereby release and agree to indemnify, defend 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 Releasees' negligence, to the fullest extent of the law. I have instructed the minor participant as to the above warnings and conditions and their ramifications. I, the undersigned, acknowledge that I have read the Assumption Of Risk, General Release And Waiver Of Liability and I understand its contents, and that my signature below expressly waives any rights I may have to sue Releasees for injuries and damages.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Date Started:

Referred by:

Occupation:

Medical Information (Allergies & Other):
Chose the appropriate line:*

If aware, describe:

(If necessary, please attach a report from your primary care physician or treating medical practitioner.) 

By my signature below, I hereby certify that the information provided herein (or attached hereto) is complete and correct and thatSPpriencgiMsiountmay reasonably rely on such information for purposes of my participation in and returning from any activities offered. 

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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