Name *

First Name

Last Name

Phone *

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Date of Birth *

MM

DD

YYYY

Emergency Contact Name *

First Name

Last Name

Emergency Contact Number *

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GDPR and Data Consent

Please confirm that you are happy to receive communication from our company regarding our services and have photos and training videos during class for advertising purposes.

Yes

No

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by your doctor? *

Yes

No

Do you feel pain in your chest when you perform physical activity? *

Yes

No

In the past month, have you had chest pain when you were not performing any physical activity? *

Yes

No

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes

No

You have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes

No

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *

Yes

No

Do you know any other reason why you should not engage in physical activity, such as any other condition, including pregnancy? *

Yes

No

I confirm that the information I have provided is accurate to the best of my knowledge and should this information change, I will inform 222 Jiu Jitsu as soon as possible. I also acknowledge that a change to the details listed could result in non-attendance of sessions. • Please note that no liability is accepted for any loss of or damage to any articles, which you may bring with you to classes. Equally, liability is not accepted for loss of or damage to motor vehicles or their contents and these are left at the owner’s risk.. • Please note that every measure has been taken to follow Government guidance to reduce the risk of contracting COVID-19. Any person taking part in 222 Jiu Jitsu Classes does so at their own risk and no liability is accepted for any person contracting COVID-19 as a result of attending. *

Yes

No

“I confirm that where any medical condition, discomfort or injury which may be affected by physical activity applies or becomes applicable at any time when I am participating in a class, I am responsible for checking with my doctor to ensure I am able to participate in this activity.” *

Yes

No

I agree to this waiver of claims and liability. By ticking the ‘YES’ Box I acknowledge that I have read this agreement and will abide by all rules of 222 Jiu Jitsu. Agreeing to this waiver also means that the I release 222 Jiu Jitsu, Tyrone Elliott, and its instructors from any liability in case of injury or death from the instruction at 222 Jiu Jitsu.  In consideration of being allowed to attend this Brazilian Jiu Jitsu/Grappling/Self-Defence/Kids Class, I acknowledge that Brazilian Jiu Jitsu/Grappling/Self-Defence/Kids Class are physical activities and that participation may result in serious injury including death, and or other damage, due not only to the undersigned/students actions, inaction or negligence, but also to that of others associated with and or present at these or other classes. Furthermore, I acknowledge that there may be risks not known to me and or not reasonably foreseeable at this time. I personally, totally and completely assume all risks involved or in any way related to my participation in this Brazilian Jiu Jitsu/Grappling/Self- Defence/Kids Class whether known or unknown to me at the present time. Participation in this Brazilian Jiu Jitsu/Grappling/Self-Defence/Kids Class is voluntary and entirely of my own free will. I hereby represent and certify that I am in good physical condition, and have no diseases, injuries or other physical or mental conditions that would impair my ability to participate in the Brazilian Jiu Jitsu/Grappling/Self-Defence/Kids Class. I hereby waive claim of accidental and or negligent damages or injury against 222 Jiu Jitsu, Tyrone Elliott, its instructors and any physical location where a 222 Jiu Jitsu class is taught. I also certify that I will be covered by a medical insurance plan (NHS) and will assume responsibility for all bills/costs associated with injuries sustained while attending or participating in a 222 Jiu Jitsu class or seminar.  *

Yes

No

I have read and understood the Terms and Conditions *

Yes

No