Health Waiver

Health Waiver

myBJJ Team thank you for taking the time to complete this questionnaire as recommended by Fitness Australia, Exercise and Sports Science Australia (ESSA) and Sports Medicine Australia (SMA). Please answer each question carefully as this information will contribute to you achieving your goals and ensure the safety of your training.
Full Name:*

First NameLast Name
Gender*
Occupation*
Date of Birth*

DayMonthYear
Date
Age*
(In years)
Mobile*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact - Name*
Emergency Contact - Phone*
How did you hear about us? *
If you were referred from a current member, please list them here so we may thank & reward them.
Goals*

FitnessMartial Arts KnowledgeWeight-LossSocial / FunNew ChallengeSelf-DefenceCompetitionOther
Are you a current gym member? (Weights gym - not BJJ)*

YesNoNo, but I want to be!
Gym Interests*

WeightsCardioGroup ClassesPersonal TrainingNone of the above
Martial Arts Knowledge*

Never Trained BeforeTrained Martial Arts BeforeCurrently Training
If you selected 'Never trained before', please skip to Medical History.

If you selected 'Trained martial arts before' or 'Currently training' please state below:
Particular Martial Arts Style:
Rank Achieved:
School/Academy:
Number of year(s) studied:
Do you take any medications on a regular basis? If yes, please list below:*
Do you suffer from any of the following:*

DiabetesHeart problemsAnginaHigh Blood PressureHigh CholesterolLung Disorder (asthma, emphysema, etc.)EpilepsySeizuresDizzy Spells/FaintingConvulsionsNONE OF THE ABOVE
(In the past 12 months) have you experienced:*

ConcussionSevere CrampsPersistent NauseaSevere Muscle Pain/SorenessSevere Joint Pain/SorenessNONE OF THE ABOVE
(Women) Are you currently pregnant?

YesNo
Do you have any allergies? If yes, please indicate below:
Are you aware of any medical reason that might prevent you from participating in exercise?*

YesNo
Application and Agreement
If you answered yes to any statements in medical history on this page, it is recommended you consult your Medical Practitioner or appropriate Allied Health Professional before engaging in exercise. You may be requested to provide a medical clearance before commending exercise. By signing this form, I acknowledge that I have read & understood this waiver. I acknowledge that I have no injuries, physical restrictions, disabilities or any predispositions to sickness or injury, which may be aggravated or adversely affected as a result of my participation. I acknowledge & recognize that martial arts training (Brazilian Jiu-Jitsu, Judo, Submission Grappling & Mixed Martial Arts – including children’s martial arts) may be a hazardous activity & therefore I train at my own risk & will not seek to penalize, prosecute or claim compensation from the organizers, sponsors, trainers or participants of the programs for any injury, loss or damages. The information in this form is strictly confidential & subject to laws & regulations contained in the Privacy Laws, enacted December 2001.
Signature (Member/Guardian):*

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