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BRUNO DIAS BRAZILIAN JIU JITSU ACADEMY

1536 SUNRISE PLAZA DR SUITE 104

CLERMONT, FL 34714

(352) 432-3111

www.bddjjacademy.com


WE’RE SORRY TO SEE YOU GO

1. If you decide to reactivate your membership in the future (and we hope you do) membership rates in effect at the time of reactivation will be applicable as membership rates are subject to change.

2. If you would like to put your membership on hold instead of canceling, you can submit a Membership Hold Request for a 30, 60 or 90 day period.

3. Your membership will be canceled 30 days from the submission of the form below. Note that if you have a scheduled renewal payment within this 30-day period, the payment will be processed as scheduled. All payments are non-refundable.

4. Agreements are auto renewed unless the MEMBERSHIP CANCELLATION FORM is submitted to us at least 30 days prior to your scheduled auto renewal.

5. If you’re sure you’d like to cancel, just complete and submit the form below 30 days prior to your next scheduled payment. This will serve as your 30-day written cancelation notice as required by your membership agreement.

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Is there anything we can do to earn your business back?
Please select the option below that best describes your reason for leaving.*
How would you rate staff attention to your fitness goals and needs?*
Overall, how would you rate your experience?*
How likely are you to recommend our gym to friends/family?*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
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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