Name *

First Name

Last Name

Phone *

(###)

###

####

Package *

6 Class Package $210

Single Class $50

Dates *

April 6th

April 13th

April 20th

April 27th

May 4th

May 11th

Minor's Guardian Name

In case of a minor please put the guardian's name

First Name

Last Name

Medical Consent and Release: *

I hereby approve my application, or that of my minor child, for participation in the Women's Self-Defense Program at Ethos Jiu Jitsu. I consent to receiving, or my minor child receiving, medical examination or treatment by a qualified physician or hospital in the event of a medical emergency during participation in this program.

Confirmed

Medical and Media Waiver for Women's Self Defense Program *

I hereby approve the application for participation in the Women's Self Defense Program at Ethos Jiu Jitsu and give my consent to myself or the minor being given a physical examination or treatment by a physician or hospital in case of a medical emergency. I further agree to myself or the minor taking part in the program's various activities and will not hold the members of the board, staff, leaders, or volunteers responsible or liable in any way for harm or injury which may occur while participating in the same. It is agreed that the parent or guardian will not hold Ethos Jiu Jitsu responsible for the welfare or whereabouts of the participant. Professional supervision will be provided during the program. If the participant or guardian does file a complaint against the Club, the participant or guardian agrees to pay for Ethos Jiu Jitsu’s legal fees. I further grant Ethos Jiu Jitsu and the media, in any form, permission to publish/use photographs or videotape footage of myself or the minor for any purpose relating to Ethos Jiu Jitsu and release Ethos Jiu Jitsu and any media of responsibility from the use of such photographs or footage.

Confirmed