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Southside Brazilian Jiu-Jitsu collects the information on this form to register and administer enrolments onto programs run by SSBJJ. This information will only be disclosed if required by law.

Some medical conditions may require the provision of a medical certificate prior to training.

I believe that to the best of my knowledge, all of the information I have supplied within this questionnaire is correct. I recognise the instructors are not able to provide me with medical advice with regard to my physical fitness and ability, and with the information I have provided will be used as a guideline to the limitations of my physical ability to exercise and participate in Brazilian Jiu-Jitsu training.

I understand that participating in the activities of Southside Brazilian Jiu-Jitsu carries with it the inherent risk of physical injury, including serious injury such as permanent disability, or even death.

In consideration of being allowed to train, I hereby release and hold harmless Southside Brazilian Jiu-Jitsu, it’s Coaches, members, employees, representatives and agents in the event of my injury.

 

I have read and fully understand this waiver and agree to release Southside Brazilian Jiu-Jitsu and anyone associated to from liability for any injury or other losses I incur, including the clubs acts of negligence to the fullest extent permitted by law.

 

Today's Date: April 12, 2024

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
-Has your doctor ever told you that you have a heart condition ? *
No
Yes
-Do you experience unexplained pains in your chest during or after physical exercise? *
No
Yes
-Have you experienced an asthma attack over the past 12 months?*
No
Yes
-If you have diabetes (type 1 or type 2) and have had trouble controlling your blood glucose in the past 3 months? *
No
Yes
-Do you have any diagnosed muscle, joint or bone problems that you have been told could be made worse by participating in physical activity or exercise? *
No
Yes
-Do you have any other medical condition(s) that may make it dangerous for you to participate in Jiu-Jitsu? *
No
Yes
-Are you pregnant or have given birth in the past 3 months? *
No
Yes

Please list any allergic reactions, medical conditions, physical or medical limitations that we should be aware of and may recommend you gain a doctors clearance before beginning Brazilian Jiu-Jitsu.
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
-Has your doctor ever told you that you have a heart condition ? *
No
Yes
-Do you experience unexplained pains in your chest during or after physical exercise? *
No
Yes
-Have you experienced an asthma attack over the past 12 months?*
No
Yes
-If you have diabetes (type 1 or type 2) and have had trouble controlling your blood glucose in the past 3 months? *
No
Yes
-Do you have any diagnosed muscle, joint or bone problems that you have been told could be made worse by participating in physical activity or exercise? *
No
Yes
-Do you have any other medical condition(s) that may make it dangerous for you to participate in Jiu-Jitsu? *
No
Yes
-Are you pregnant or have given birth in the past 3 months? *
No
Yes

Please list any allergic reactions, medical conditions, physical or medical limitations that we should be aware of and may recommend you gain a doctors clearance before beginning Brazilian Jiu-Jitsu.
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
-Has your doctor ever told you that you have a heart condition ? *
No
Yes
-Do you experience unexplained pains in your chest during or after physical exercise? *
No
Yes
-Have you experienced an asthma attack over the past 12 months?*
No
Yes
-If you have diabetes (type 1 or type 2) and have had trouble controlling your blood glucose in the past 3 months? *
No
Yes
-Do you have any diagnosed muscle, joint or bone problems that you have been told could be made worse by participating in physical activity or exercise? *
No
Yes
-Do you have any other medical condition(s) that may make it dangerous for you to participate in Jiu-Jitsu? *
No
Yes
-Are you pregnant or have given birth in the past 3 months? *
No
Yes

Please list any allergic reactions, medical conditions, physical or medical limitations that we should be aware of and may recommend you gain a doctors clearance before beginning Brazilian Jiu-Jitsu.
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
-Has your doctor ever told you that you have a heart condition ? *
No
Yes
-Do you experience unexplained pains in your chest during or after physical exercise? *
No
Yes
-Have you experienced an asthma attack over the past 12 months?*
No
Yes
-If you have diabetes (type 1 or type 2) and have had trouble controlling your blood glucose in the past 3 months? *
No
Yes
-Do you have any diagnosed muscle, joint or bone problems that you have been told could be made worse by participating in physical activity or exercise? *
No
Yes
-Do you have any other medical condition(s) that may make it dangerous for you to participate in Jiu-Jitsu? *
No
Yes
-Are you pregnant or have given birth in the past 3 months? *
No
Yes

Please list any allergic reactions, medical conditions, physical or medical limitations that we should be aware of and may recommend you gain a doctors clearance before beginning Brazilian Jiu-Jitsu.
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
-Has your doctor ever told you that you have a heart condition ? *
No
Yes
-Do you experience unexplained pains in your chest during or after physical exercise? *
No
Yes
-Have you experienced an asthma attack over the past 12 months?*
No
Yes
-If you have diabetes (type 1 or type 2) and have had trouble controlling your blood glucose in the past 3 months? *
No
Yes
-Do you have any diagnosed muscle, joint or bone problems that you have been told could be made worse by participating in physical activity or exercise? *
No
Yes
-Do you have any other medical condition(s) that may make it dangerous for you to participate in Jiu-Jitsu? *
No
Yes
-Are you pregnant or have given birth in the past 3 months? *
No
Yes

Please list any allergic reactions, medical conditions, physical or medical limitations that we should be aware of and may recommend you gain a doctors clearance before beginning Brazilian Jiu-Jitsu.
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
-Has your doctor ever told you that you have a heart condition ? *
No
Yes
-Do you experience unexplained pains in your chest during or after physical exercise? *
No
Yes
-Have you experienced an asthma attack over the past 12 months?*
No
Yes
-If you have diabetes (type 1 or type 2) and have had trouble controlling your blood glucose in the past 3 months? *
No
Yes
-Do you have any diagnosed muscle, joint or bone problems that you have been told could be made worse by participating in physical activity or exercise? *
No
Yes
-Do you have any other medical condition(s) that may make it dangerous for you to participate in Jiu-Jitsu? *
No
Yes
-Are you pregnant or have given birth in the past 3 months? *
No
Yes

Please list any allergic reactions, medical conditions, physical or medical limitations that we should be aware of and may recommend you gain a doctors clearance before beginning Brazilian Jiu-Jitsu.
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
-Has your doctor ever told you that you have a heart condition ? *
No
Yes
-Do you experience unexplained pains in your chest during or after physical exercise? *
No
Yes
-Have you experienced an asthma attack over the past 12 months?*
No
Yes
-If you have diabetes (type 1 or type 2) and have had trouble controlling your blood glucose in the past 3 months? *
No
Yes
-Do you have any diagnosed muscle, joint or bone problems that you have been told could be made worse by participating in physical activity or exercise? *
No
Yes
-Do you have any other medical condition(s) that may make it dangerous for you to participate in Jiu-Jitsu? *
No
Yes
-Are you pregnant or have given birth in the past 3 months? *
No
Yes

Please list any allergic reactions, medical conditions, physical or medical limitations that we should be aware of and may recommend you gain a doctors clearance before beginning Brazilian Jiu-Jitsu.
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
-Has your doctor ever told you that you have a heart condition ? *
No
Yes
-Do you experience unexplained pains in your chest during or after physical exercise? *
No
Yes
-Have you experienced an asthma attack over the past 12 months?*
No
Yes
-If you have diabetes (type 1 or type 2) and have had trouble controlling your blood glucose in the past 3 months? *
No
Yes
-Do you have any diagnosed muscle, joint or bone problems that you have been told could be made worse by participating in physical activity or exercise? *
No
Yes
-Do you have any other medical condition(s) that may make it dangerous for you to participate in Jiu-Jitsu? *
No
Yes
-Are you pregnant or have given birth in the past 3 months? *
No
Yes

Please list any allergic reactions, medical conditions, physical or medical limitations that we should be aware of and may recommend you gain a doctors clearance before beginning Brazilian Jiu-Jitsu.
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
-Has your doctor ever told you that you have a heart condition ? *
No
Yes
-Do you experience unexplained pains in your chest during or after physical exercise? *
No
Yes
-Have you experienced an asthma attack over the past 12 months?*
No
Yes
-If you have diabetes (type 1 or type 2) and have had trouble controlling your blood glucose in the past 3 months? *
No
Yes
-Do you have any diagnosed muscle, joint or bone problems that you have been told could be made worse by participating in physical activity or exercise? *
No
Yes
-Do you have any other medical condition(s) that may make it dangerous for you to participate in Jiu-Jitsu? *
No
Yes
-Are you pregnant or have given birth in the past 3 months? *
No
Yes

Please list any allergic reactions, medical conditions, physical or medical limitations that we should be aware of and may recommend you gain a doctors clearance before beginning Brazilian Jiu-Jitsu.
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
-Has your doctor ever told you that you have a heart condition ? *
No
Yes
-Do you experience unexplained pains in your chest during or after physical exercise? *
No
Yes
-Have you experienced an asthma attack over the past 12 months?*
No
Yes
-If you have diabetes (type 1 or type 2) and have had trouble controlling your blood glucose in the past 3 months? *
No
Yes
-Do you have any diagnosed muscle, joint or bone problems that you have been told could be made worse by participating in physical activity or exercise? *
No
Yes
-Do you have any other medical condition(s) that may make it dangerous for you to participate in Jiu-Jitsu? *
No
Yes
-Are you pregnant or have given birth in the past 3 months? *
No
Yes

Please list any allergic reactions, medical conditions, physical or medical limitations that we should be aware of and may recommend you gain a doctors clearance before beginning Brazilian Jiu-Jitsu.
Parent or Guardian's Email Address

Email*

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

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
-Has your doctor ever told you that you have a heart condition ? *
No
Yes
-Do you experience unexplained pains in your chest during or after physical exercise? *
No
Yes
-Have you experienced an asthma attack over the past 12 months?*
No
Yes
-If you have diabetes (type 1 or type 2) and have had trouble controlling your blood glucose in the past 3 months? *
No
Yes
-Do you have any diagnosed muscle, joint or bone problems that you have been told could be made worse by participating in physical activity or exercise? *
No
Yes
-Do you have any other medical condition(s) that may make it dangerous for you to participate in Jiu-Jitsu? *
No
Yes
-Are you pregnant or have given birth in the past 3 months? *
No
Yes

Please list any allergic reactions, medical conditions, physical or medical limitations that we should be aware of and may recommend you gain a doctors clearance before beginning Brazilian Jiu-Jitsu.
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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