|
Em Português
PERSONAL INFORMATION Applicant Name: _______________________________________________________ Telephone: ______________ Fax: _______________ E-mail: ___________________ Street Address: ________________________________________________________ City: ____________________________ State: ________ Zip Code: ________ Birth date: ____________________________ Sex: ________ Uniform Size: ________ Height: ________ Weight: ________ Social Security No:____________________________ EMPLOYER INFORMATION Employer Name: ________________________ Company Name: ________________ Street Address: ________________________________________________________ City: ____________________________ State: ________ Zip Code: ________ Telephone: _____________________________ Fax: _________________________ If you run your own school, please supply the following information: 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? ________ PREVIOUS TRAINING
Street Address: ________________________________________________________ City: ____________________________ State: ________ Zip Code: ________ Phone: ___________________________ Instructor: ________________________ Type of Martial Arts: _______________________________________________ Total Years of Training: _______ Rank Achieved: ________ IN CASE OF EMERGENCY PLEASE NOTIFY
Home Phone: _____________________ Business Phone: _____________________ PARTICIPANT AGREEMENT, RELEASE AND ACKNOWLEDGMENT OF RISK 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:
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: ____________________________ 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 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:
_______ 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. |