Toddler Jiu Jitsu Free Trial Class Appointment Request

Toddler Jiu Jitsu

Free Trial Class Appointment Request
Child's Name*

First NameLast Name
Child's Age*
Child's Date of Birth*
Sibling's Name (if registering for more than one child)

First NameLast Name
Sibling's Age
Sibling's Date of Birth
Parent / Legal Guardian Name*

First NameLast Name
Phone Number*
Email Address*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about our Toddler Jiu Jitsu class?*

Walked by and saw the sign / window posterSaw a post in a Facebook groupReferralGoogle SearchOther
Who were you referred by?

Emergency & Health Information
Designated Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Relation to Student*
Does your child have any allergies, previous injuries, or health conditions that you would like us to be aware of?*
Does your child have any attention deficit, sensory processing, or behavioral needs?*

Child's Previous Experience
Does your child attend school (daycare or pre-school)?*

YesNo
Has your child tried other physical activities in a group setting (e.g., gymnastics, soccer, etc.)? If so, how was their experience?*
How would you describe your child's personality?*

Parent Questionnaire
What is the main reason you want your child to train Brazilian Jiu Jitsu?*
Have you (the parent) ever trained Brazilian Jiu Jitsu before?*

Yes, I have experience training Brazilian Jiu JitsuNo, I have never done Brazilian Jiu Jitsu
Please describe your previous Brazilian Jiu Jitsu experience:*
Do you (the parent) have previous experience with any other combat sports (wrestling, boxing, kickboxing, etc.) or martial arts?

Yes, I have previous experience with other combat sports and/or martial artsNo, I have never trained any combat sports or martial arts
Please describe your previous experience with other combat sports / martial arts:*

Class Information & Appointment Request
Toddler Jiu Jiu Jitsu Class takes place on Saturday mornings.

Session 1 meets on Saturdays at 9:00-9:30am.

Session 2 meets on Saturdays at 10:00-10:30am.

Session 3 meets on Saturdays at 11:00-11:30am.

These are small group sessions with limited enrollment. Memberships will be offered on a first-come, first-served basis.

We are now taking Free Trial Class Appointment Requests for all sessions.

Requests are reviewed daily. Once we receive your request, we will contact you to confirm your appointment.
Request a Free Trial Class
Which session would you like to attend?*

Session 1 (Saturdays @ 9:00-9:30am)Session 2 (Saturdays @ 10:00-10:30am)Session 3 (Saturdays @ 11:00-11:30am)
Please select your desired appointment date:*

MonthDayYear
Date

Waiver of Liability

Please complete on behalf of your child.
I am in good physical health. I am in good physical condition; do not suffer from any heart, lung, or other bodily ailment; and am in all respects physically fit to engage in training Jiu Jitsu and all associated physical activities.
I agree
I consent to physical contact as necessary for training Jiu Jitsu. Physical contact will be used by the instructors, other students, and authorized individuals as part of instruction. I have been advised of this fact and give full consent to any physical contact as may be required or customary to training Jiu Jitsu.
I agree
I release the school of liability for accident, injury, or death. In recognition of the possibility of accident, injury, or death connected with training Jiu Jitsu, I waive any right or cause of action of any kind arising as the result of such activity from which any liability may or could accrue to the school, its agents, employees, instructors, and/or students.
I agree
I am responsible for my own medical coverage. I acknowledge and agree that it is my own responsibility to cover any medical bills I may incur, and to cover myself with any medical insurance I deem appropriate. I will not and cannot make any claim for medical coverage resulting from any accident, injury, or death incurred at the school facility.
I agree
I authorize medical assistance in case of an emergency. I hereby authorize licensed medical personnel to perform any medical assistance deemed necessary, and agree to bear the expense of any such treatment.
I agree
The school is not responsible for any loss or theft of personal property. The school shall not be liable for personal property injuries, damages, loss, or theft, even in the event of negligence, fault, or failure on the part of the school to use due care.
I agree
I consent to being photographed and recorded on video. I consent to the school taking photographs or video images of me while in class, at school events, or otherwise on the public premises of the business. I grant the school the right to use my image or likeness in any advertising, promotion, marketing materials, any and all social media, print media, and on the school’s website, and waive any compensation thereof.
I agree
In signing this release, I acknowledge and represent that I have read the foregoing Waiver of Liability, understand it, and sign it voluntarily. I agree to all its terms and conditions. I intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.
Signature

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Toddler Jiu Jitsu

Emergency & Health Information

Child's Previous Experience

Parent Questionnaire

Class Information & Appointment Request

Request a Free Trial Class

Waiver of Liability