Student's NameDate of BirthMonthDayYearStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeCountry AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweGenderMaleFemalePhoneEmail AddressHave you trained before?YesNoIf so, how long/what rank?Emergency ContactEmergency PhoneRelease of Liability & WaiverBy signing below, I hereby acknowledge and understand that marital arts involve physical contact that can test a person’s physical and mental limits and that injuries may occur at any time during my training. I hereby knowingly and voluntarily assume the risks and all responsibility for losses, costs, and damages incurred as a result of my participating in martial arts including, but not limited to: dangers of serious bodily injury or death caused by my own actions, or inactions, or the actions or inactions of others. I intend to be legally bound hereby for myself, my heirs, executors, administrators, personal, or legal representatives, forever waive and release any and all rights and claims for damages I may have against the individuals or agents of Billings Jiu Jitsu LLC including Gwendolyn Kern, all the instructors, participants, staff, or agents, individually or collectively (“Releasees”) from all liability including claims and suits at law or in equity for any injury or injuries, fatal or otherwise, which may result directly or otherwise from my participating in or traveling to or from classes, meetings, or demonstrations. I will indemnify, save and hold harmless each of the Releasees from any litigation expense, attorney fees, loss liability, damage or cost any may incur as the result of any such claim. I also give my consent to be photographed or videotaped for inclusion in any marketing or promotional materials. I hereby declare that I have read this agreement, fully understand its terms and am competent to sign it, understand that I have given up substantial rights by signing it and have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by the laws of the Unites Stated of America and agree that if any portion of this agreement is held to be invalid by a legally recognized Courts of the United Stated of America, that the balance, notwithstanding, shall continue in full force and effect.SignatureStart signing your signature hereYour browser does not support e-Signature field.DateI am under the age of 18 and my parent or guardian has read and completed the section below. (If student is under 18 years of age, a parent or guardian must execute, in addition to the foregoing Release of Liability and Waiver, the following, for and on behalf of the minor.) The undersigned, the parent and natural guardian or legal guardian of (minor’s name listed above) executes the foregoing Release of Liability and Waiver for and on behalf of the minor named herein. I hereby bind myself, the minor, and all other assigns to the terms of the above Release of Liability and Waiver. I represent that I have legal capacity and authority to act for and on behalf of the minor named herein, and agree to indemnify and hold harmless the Releasees in the Release of liability and Waiver for any claims or liabilities assessed against them as a result of any insufficiency of my legal capacity or authority to act for and on behalf of the minor in the execution of the Waiver and Release. I fully consent to this child’s participation in martial arts and I also give my expressed permission for this minor to be photographed or videotaped for the purpose of marketing and promotional materials used in conjunction with Billings Brazilian Jiu Jitsu.Parent or Guardian NameParent/Guardian SignatureStart signing your signature hereYour browser does not support e-Signature field.DateSend Message