New Member Registration Form

SMARTSTART ENROLLMENT
We're so glad to have your child join our SmartStart program! This e-form has everything you need to get them enrolled. You may save your information and return later if needed, and you'll have the opportunity to print and/or download your completed form once submitted.

If you have any questions, or need assistance, please feel free to reach out to us. You can contact us through email at info@nexjenbjj.com or by calling Coach Vince at 859-684-4281.
Fields marked with * are required.
Billing email address associated with this membership: *
This email address will also be used to save your information if you need to complete later.
Billing Communication Preferences*
Primary Contact Name (Parent or Guardian)*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact Phone Number*
Please enter a valid phone number.
Primary Custodial?
A primary (or joint) custodial parent or guardian must sign the student waiver form. Please contact us with questions regarding this section.
Student Name*

First NameLast Name
Student Date of Birth*

MonthDayYear
Date
FemaleMale

Click here to add additional student
Student Name

First NameLast Name
Student Date of Birth

MonthDayYear
Date
FemaleMale
Student Name

First NameLast Name
Student Date of Birth

MonthDayYear
Date
FemaleMale

EMERGENCY CONTACT & MEDICAL INFORMATION
Emergency Contact Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to Student:*
Medical conditions or allergies?

GENERAL WAIVER & RELEASE
INJURY WAIVER

I hereby affirm that I am in good physical condition and do not suffer from any disability that would prevent or limit my participation in any classes taken at NexJen BJJ. I hereby release NexJen BJJ, its employees, owners, and participants from any claims, demands, and causes of action arising from my participation during any class at NexJen BJJ. I fully understand that I may injure myself and I hereby release NexJen BJJ, its owners, employees, and participants from any liability now or in the future, including, but not limited to pulls or tears (muscles, ligaments or tendons), muscle strains, broken bones, joint dislocations, hyper extensions of bones and joints, ankle, knee, hip, lower back, shoulder, elbow, wrist, finger or toe injuries, heart attacks, strokes, loss of vision, concussion, dental trauma, death, or any other injury or illness however caused, occurring during or after my participation in any class taken at NexJen BJJ.

WAIVER OF LIABILITY

I understand and agree that NexJen BJJ is not responsible for property that is lost, stolen, or damaged while in, on, or about the premises.

COMPLIANCE WITH RULES
I agree to comply with all rules imposed by NexJen BJJ regarding the use of the facilities and equipment. I agree to conduct myself in a controlled and reasonable manner at all times, and to refrain from using any equipment, training, or property in a manner inconsistent with its intended design and purpose. I hereby affirm that I have read fully, understand and agree with the above statements.

PHOTO/IMAGE RELEASE I hereby grant NexJen BJJ and its agents permission to use photographic portraits, pictures, digital images or videotapes of me and/or my minor child, or in which I/they may be included in whole or part, or reproductions thereof in color or otherwise for any lawful purpose whatsoever, including but not limited to use in any NexJen BJJ publication or on the NexJen BJJ website, without payment or any other consideration. I hereby waive any right that I may have to inspect and/or approve the finished product or the copy that may be used in connection therewith, wherein my likeness appears, or the use to which it may be applied. On behalf of myself, my heirs, representatives, executors, and assigns, I hereby release, discharge, and agree to indemnify and hold harmless NexJen BJJ and its agents from all claims, demands, and causes of action that I have or may have by reason of this authorization, including any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said photos or videotapes, or in processing tending towards the completion of the finished product.

I understand that this permission is revocable at any time when requested in writing.
Please indicate that you have reviewed the General Waiver and Release*

I agree to the general waiver and release conditions as noted above.

SMARTSTART & GENERAL GYM RULES

The understanding and following of our gym rules is very important at NexJen BJJ. We strive to provide a safe, clean and family friendly environment for our members, instructors and guests. We emphasize being excellent training partners and treating everyone in the gym with respect. Please review the SmartStart rules with your child. The general gym rules are also included below for your information.
SmartStart Rules to review with your child:

No shoes or sock feet on the mats.

No bare feet in the restrooms.

Do not leave the mat without Coach's permission.

No chewing gum, eating or drinking while on the mats.

No talking when Coach is talking.

Don't try to hurt your team mates.

We say please, thank you, yes sir, no sir.

SmartStart Rules for parents:

a parent must remain in the gym during class

If your child is hurt/upset/misbehaving/talking etc- let Coach handle it.

General Gym Rules

No shoes or sock feet on the mats.

No bare feet in the restrooms. Wear flip flops or slides into the restrooms.

No chewing gum, eating or drinking while on the mats .

Please arrive at least 10 minutes prior to the start of class. If you are late to class, wait for the instructor's acknowledgement before joining the class.

Come to class well groomed. Both you and your gi should be clean. Long hair should be secured and finger and toe nails trimmed. Jewelry and piercings should be removed if possible, and open cuts must be covered at all times.

Be mindful of your words. Profanity in the presence of children and guests is not allowed. Gi and clothing must not have any offensive language or imagery.

Do not try to intentionally harm your training partner. Fighting, abusive behavior or language or threats of harm are not allowed.

Report any injury to your instructor immediately. Do not train when sick. Bring any skin rashes to the instructor's attention.

Any form of tobacco use or vaping is not permitted inside or outside within 10 feet of the front of the gym.

Personal firearms should be left in your locked vehicle, or MUST be secured in a portable locking gun box or with a trigger lock and placed in the office when inside the gym. ABSOLUTELY NO EXCEPTIONS.
Please indicate that you have reviewed the SmartStart rules with your child(ren) and the General Gym rules for yourself*

I have reviewed the SmartStart rules with my child(ren).

SmartStart Billing Agreement
SmartStart fee is $40 per month, plus KY sales tax

There is a one time, non-refundable enrollment fee of $100, which includes a basic gi and belt for your child.

Monthly invoices are emailed on the last day of the month and are due by the 7th of the following month. If not paid by the 10th, a $10 late fee will be applied. After the 15th, enrollment will be terminated.
Final Submission
A link to our payment form will be shared on the next page. Submission of this form is your acknowledgement that you agree to the waiver and release conditions, have reviewed our SmartStart and general gym rules and the billing agreement. This form must be signed by the parent or guardian of the student(s). *
FULL NAME
Signature*

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SMARTSTART ENROLLMENT

EMERGENCY CONTACT & MEDICAL INFORMATION

GENERAL WAIVER & RELEASE

SMARTSTART & GENERAL GYM RULES

SmartStart Billing Agreement

Final Submission