Applicant Name: _______________________________________________________

Telephone: ______________ Fax: _______________ E-mail: ___________________

Street Address: ________________________________________________________

City: ____________________________ State: ________ Zip Code: ________

Birth date: ____________________________ Sex: ________ Uniform Size: ________

Height: ________ Weight: ________ Social Security No:____________________________

Employer Name: ________________________ Company Name: ________________

Street Address: ________________________________________________________

City: ____________________________ State: ________ Zip Code: ________

Telephone: _____________________________ Fax: _________________________

Name of School: ________________________________________________________

Street Address: ________________________________________________________

City: ____________________________ State: ________ Zip Code: ________

School Phone: _____________________

In Business Since: ________________ Number of Instructors Employed: ________

Are you interested in becoming a Rickson Gracie Jiu-Jitsu Representative? ________

Martial Arts School Attended: __________________________________________

Street Address: ________________________________________________________

City: ____________________________ State: ________ Zip Code: ________

Phone: ___________________________ Instructor: ________________________

Type of Martial Arts: _______________________________________________

Total Years of Training: _______ Rank Achieved: ________

Name: ___________________________ Relationship: _______________________

Home Phone: _____________________ Business Phone: _____________________

In consideration of the services of Rickson Gracie International Jiu-Jitsu Center and/or Rickson Gracie Jiu-Jitsu Center and/or Rickson Gracie International Jiu-Jitsu Association and/or Rickson Gracie and/or Samurai Enterprises, LLC, their agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as "Samurai Enterprises"), I hereby agree to release and discharge Samurai Enterprises on behalf of myself, my children, my parents, my heirs, assigns, personal representative and estate as follows:

1. I acknowledge that participation in the martial arts entails unknown and unanticipated risks which could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. The risks include, among other things: intense, stressful and strenuous exercises with body contact. I expressly consent to confront these known and unknown dangers and further agree, understand and recognize that these risks may result in serious injury or illness including but not limited to: bruises, bloody noses, broken bones, sprains, dislocations, heart attacks or other cardiovascular disease, or other serious injury resulting in death and/ or property damage. Furthermore, Samurai Enterprises’ employees have difficult jobs to perform. They seek safety, but they are not infallible. They might be ignorant of a participant’s fitness or abilities. They may give inadequate warnings or instructions, and the equipment being used might malfunction.
2. I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks.
3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless, Samurai Enterprises from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of Samurai Enterprises’ equipment or facilities, including any such claims which allege negligent acts or omissions of Samurai Enterprises.
4. Should Samurai Enterprises, or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.
5. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I have no medical or physical conditions which could interfere with my safety in this
   activity, or else I am willing to assume – and bear the costs of – all risks that may be created, directly or indirectly, by any such condition.
6. In the event that I file a lawsuit against Samurai Enterprises, I agree to do so solely in the state of California, and I further agree that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state.

By signing this document, I acknowledge that if I, or any other person or persons, is hurt in any way, or property is damaged during my participation in this activity, I hereby waive any right to any claim and/or lawsuit against Rickson Gracie International Jiu-Jitsu Center and/or Rickson Gracie Jiu-Jitsu Center and/or Rickson Gracie International Jiu-Jitsu Association and/or Rickson Gracie and/or Samurai Enterprises, L.L.C. on the basis that any claim I may have is hereby released and acknowledged by my signature below. I have had sufficient opportunity to read this entire document. I acknowledge reading this document and I understand it completely. I agree to be bound by the terms of this document.

I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms.

Signature of Participant: ______________________________________________
Print Name: ____________________________________________________________
Address: _______________________________________________________________
         _______________________________________________________________
Phone: _________________________      Date: ____________________________
PARENT 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 Rickson Gracie International Jiu-Jitsu Center and/or Rickson Gracie Jiu-Jitsu Center and/or Rickson Gracie International Jiu-Jitsu Association and/or Rickson Gracie and/or Samurai Enterprises, LLC to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold harmless Rickson Gracie International Jiu-Jitsu Center and/or Rickson Gracie Jiu-Jitsu Center and/or Rickson Gracie International Jiu-Jitsu Association and/or Rickson Gracie and/or Samurai Enterprises, LLC from any and all claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation by Minor.

____________________________________________________________
Print Name
__________________________________________________________________
Parent or Guardian's Signature                                                    Date
FORM OF PAYMENT
Cash ___, Check ___, Money Order ___, Visa ___, Mastercard ___ 

Card Number ________________________________________ Expr Date _________

Signature ____________________________________________ Date ___________

Amt. $_____________ Check/Moneyorder # _____________

Name appearing on Check/Moneyorder/Acct. ______________________________________

Please make all payments payable to Rickson Gracie International Jiu-Jitsu Association, and send along with the completed application to the address below:

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

_______ Please send me a Representative Application.

The Association has the right to refuse or cancel any membership due to any misconduct, in the eyes of the Association, and/or noncompliance with the terms and conditions set forth herein.

© Samurai Enterprises, L.L.C.