seminarform

Seminar Registration Form

Please print out this form, fill it in completely, and mail it to:

Rickson Gracie International Jiu-Jitsu Association
15237 Sunset Blvd., Suite 50
Pacific Palisades, CA 90272

PERSONAL INFORMATION

Name: ______________________________________ Member No._______________

E-mail: _____________________________________

Telephone: _____________________________ Fax: ____________________________

Address: _______________________________________________________________

City: __________________________ State:_____________ Zip Code:_____________

Are you a professional fighter? Y / N

IN CASE OF EMERGENCY PLEASE CONTACT

Name:____________________________________

Relationship:_______________________________

Phone:____________________________________

SEMINAR & BELT TESTING (belt tests are for Members only)

A MARTIAL ARTS BACKGROUND IS NOT REQUIRED
TO ATTEND BASIC LEVEL SEMIARS

In order to receive an Intermediate Level Certificate from the Rickson Gracie International Jiu-Jitsu Association, you must have 10 hours of Basic Level Seminar training under an Official Representative. After each Basic Level Seminar, you will be sent a Certificate of Completion for the seminars hours, wich will be applied toward fulfilling the 10 hours requirement.

Please specify which seminar and day(s) attending:

___________________________________________________________________________

___________________________________________________________________________

Belt Test Desired :

____ White belt/Phase I

____ Blue Belt/Phase I

FORM OF PAYMENT

(Foreign applicants must pay in U.S. dollars)

Cash ____ Check ____ Money Order ____ Visa ____ Mastercard ____

Credit Card Number _______________________ Exp Date _________

Signature _________________________________________________

Total Due_________ Date _________ Check/Money Order #________

Name on CreditCard/Check/Money Order _______________________

PARENT’S OR GUARDIAN’S ADDITIONAL INDEMNIFICATION
(must be completed for participants under the age of 18)

In consideration of___________________________________(print minor’s name) ("Minor") being
permitted by the Rickson Gracie International Jiu-Jitsu Association/ Samurai Enterprises, LLC to
participate in its activities, I further agree to indemnify and hold harmless Rickson Gracie International Jiu-Jitsu Association/ Samurai Enterprises, LLC from any and all claims which are brought by, or on behalf of Minor, ad which are in any way connected with such use or participation by Minor.

Parent or Guardian Signature _____________________________________

Print Name____________________________ Date ___________________

I understand that by entering this Seminar I will be training at my own risk and that the Rickson Gracie International Jiu-Jitsu Association/ Samurai Enterprises, LLC is not responsible or liable for injuries or demages sustained during this Seminar.

Signature______________________________ Date ___________________