Riverbend Female Self Defense Class Registration
  • Riverbend Female Self-Defense Registration

    Please complete the form below to register to the Free Female Self Defense Class April 4, 2026 from 2:00p.m. - 3:30p.m.
  • Image field 43
  • Participants Information



  • If participant is under the age of 18, we must have parents information and signature.

  •  - -
  • Format: (000) 000-0000.
  • Parent/Guardian Information

  • Format: (000) 000-0000.
  • Emergency Contact

  • Format: (000) 000-0000.
  • Medical Notes

  • Waiver and Acknowledgements

    • Assumption of Risk, Waiver of Liability, and Indemnification AgreementSUP River Bend Jiu Jitsu Academy LLC is a Virginia limited liability company (the "Company") that provides training, exercises, and other activities related to Brazilian Jiu-Jitsu (the "Activities"). The PARTICIPANT/PARENT (defined below) intends to participate in such activities provided by the Company.While there are many benefits to the Activities, it is very important that the PARTICIPANT/PARENT (which refers to either an ADULT Participant, OR a MINOR Participant and his/her PARENTS/GUARDIANS) understands that all physical activities include some inherent risks of injury; these inherent risks cannot be eliminated regardless of the care taken to avoid injuries. Some examples of these inherent activity risks include, but are not limited to, falls, strained muscles, broken bones, concussions, cuts, injuries related to the physical or other health-related conditions of participants, etc. Other inherent risks include, but are not limited to, the conditions of the real property where the activities take place and risk of disease, including communicable diseases such as COVID-19, influenza, and other viral or bacterial infections. Risks related to participant and co-participants include, but are not limited to, erratic, careless, or negligent actions of co-participants or participant; errors of judgment or lack of attention of participant or co-participant.The Company believes that it is important for the PARTICIPANT/PARENT to understand that certain kinds of injuries may occur, including but not limited to, scratches; bruises; minor cuts; muscle pulls; muscle soreness; sprains; ankle, knee, and other joint injuries (e.g., tendon, ligament); broken bones; concussions; tendonitis; stress fractures; permanent disability; paralysis; heart attacks; and death.ASSUMPTION OF INHERENT RISKS: I have read the above warning regarding the nature of the Activities and some of their associated risks. I affirm that 1) I understand the demands of the Activities relative to my physical condition and skill level, 2) I understand the types of injuries that may occur as a result of Activities and 3) I understand their potential impact on my well-being, lifestyle, and potential future careers. I hereby assert that my participation is voluntary and that I knowingly assume all inherent risks, both known and unknown.WAIVER OF LIABILITY FOR NEGLIGENCE: IN CONSIDERATION OF PERMISSION FOR MYSELF AND/OR MINOR PARTICIPANT TO PARTICIPATE IN THE ACTIVITIES AND SERVICES TODAY AND ON ALL FUTURE DATES, I, THE PARTICIPANT/PARENT, ON BEHALF OF MYSELF, MY SPOUSE, MY HEIRS, PERSONAL REPRESENTATIVES, ASSIGNS, OR OTHERS MAKING A CLAIM ON BEHALF OF MYSELF OR MY MINOR PARTICIPANT [HEREAFTER REFERRED TO AS RELEASING PARTIES] DO HEREBY RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE THE COMPANY, OR ANY OF THE COMPANY'S OWNERS, DIRECTORS, OFFICERS, EMPLOYEES, MEMBERS, MANAGERS, VOLUNTEERS, INDEPENDENT CONTRACTORS, AND AGENTS, [HEREAFTER REFERRED TO AS PROTECTED PARTIES] FROM LIABILITY FROM ANY AND ALL CLAIMS ARISING FROM 1) THE NEGLIGENCE OF THE COMPANY, OR OTHER PROTECTED PARTIES AND/OR ARISING FROM 2) THE PRESENCE OF MYSELF AND/OR MINOR PARTICIPANT ON THE PREMISES USED BY THE COMPANY FOR THE ACTIVITIES.This Assumption of Risk, Waiver of Liability, and Indemnification Agreement applies to, but is not limited to, any/all of the following:• Communicable illnesses (including COVID-19, influenza, and other viral or bacterial infections; personal injury (including death), and/or economic loss to the PARTICIPANT/PARENT arising from participation in the Activities (including, but not limited to, training, exercises, events, and while at the site of such Activities).• Any and all claims resulting from the damage to, loss of, or theft of property.• The release of the Company and all Protected Parties from any claims and rights that I and/or MINOR PARTICIPANT 1) now hav 
    • Powered by Jotform SignClear
  • Should be Empty: