Student Registration

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Please list any underlying health concerns

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Liability Release Liability Release I ACKNOWLEDGEMENT AND WAIVER OF LIABILITY 1. Student represents and warrants that (s)he is in good health and has no physical or mental disability, impairment or pre-existing condition that may otherwise prevent him/her from safely participating in the listed program’s activities. Student acknowledges the advice of PCBJJ that everyone should receive a physical examination prior to participating in any strenuous physical activity, including those held at PCBJJ. Student understands that the activities involved in the listed program are physically strenuous, violent, and potentially dangerous and may expose him/her to serious physical injury. Student understands and acknowledges that PCBJJ has taken every reasonable precaution to ensure the safety of all of its members. Student further agrees to immediately notify PCBJJ management in the event that conditions change during the course of his/her membership for any reason (i.e., accident, illness, or other medical condition). 2. Physical contact will be used by employees of the school, other students and authorized individuals, as part of the course of instruction. Student has been advised of such fact and gives full consent to any physical contact as may be required or customary to Brazilian jiu jitsu training. 3. APPLICANT, STUDENT, OR INVITEE (I.E., GUEST, FREEE CLASS PASS, TRIAL MEMBER, COUPON USER, ETC.) AND/OR THEIR RESPECTIVE PARENTS/GUARDIANS (FOR APPLICANTS/STUDENTS/INVITEES UNDER 18 YEARS OF AGE), IN CONSIDERATION FOR APPLICANT’S PARTICIPATION IN ACTIVITIES ADMINISTERED BY PCBJJ MANAGEMENT, INCLUDING OWNERS, OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, REPRESENTATIVES, CONTRACTORS, AND SUB-CONTRACTORS, VOLUNTEERS (“STAFF”), AND PREMISE OWNER, DO HEREBY EXPRESSLY WAIVE RELEASE AND FOREVER DISCHARGE MANAGEMENT FROM ANY AND ALL LIABILITY FOR ANY PERSONAL INJURIES OR DAMAGES RESULTING FROM STUDENT PARTICIPATION IN ANY OF THE LISTED PROGRAMS’ ACTIVITIES, EITHER ON OR OFF THE FACILITY’S PREMISES, INCLUDING THOSE DUE TO ANY INTENTIONAL OR UNINTENTIONAL ACT OF MANAGEMENT OR STAFF, TO THE FULLEST EXTENT PROVIDED BY LAW. By signing below, I acknowledge that I have read and understand the Waiver of Liability and agree to abide by it. I further acknowledge that I may be photographed or filmed while attending at the premises of Port City Brazilian Jiu Jitsu, and I give my permission to Port City Brazilian Jiu Jitsu, and any affiliates to use any and all photos, video footage, and/or video streaming for promotional, sales, publicity, and advertising purposes for all media including internet. ACKNOWLEDGEMENT AND RELEASE FORM (WAIVER OF LIABILITY) COVID-19 Supplement This is a supplement to our standard waiver of liability to include special COVID-19 related items. 1- The undersigned acknowledges that the disease caused by the novel coronavirus (COVID-19) has been confirmed throughout the United States. In accordance with the most recent guidance and protocols issued by the Centers for Disease Control and Prevention (CDC) and the state Department of Health for slowing the transmission of COVID-19, the undersigned hereby agrees, represents, and warrants that neither the undersigned nor such participating children shall visit or utilize the facilities, services, and programs (other than any online services) within 14 days after (i) returning from a highly impacted area subject to CDC Level 3 Travel Health Notices, (ii) exposure to any person returning from areas subject to a CDC Level 3 Travel Health Notice, or (iii) exposure to any person who has a suspected or confirmed case of COVID-19. The complete CDC Travel Health Notice is continuously updated at https://www.cdc.gov/coronavirus/2019-ncov/travelers/map-and-travel-notices.html and the undersigned agrees that they are aware of this list and the countries listed. 2-The undersigned hereby agrees, represents, and warrants that neither the undersigned nor such participating children shall visit or utilize the facilities, services, and programs (other than any online services) if he or she (i) experiences symptoms of COVID-19, including cough, shortness of breath or difficulty breathing, fever, or new loss of taste or smell, or (ii) has a suspected or diagnosed/confirmed case of COVID-19. The undersigned agrees to notify us immediately if he or she believes that any of the foregoing access/use restrictions may apply. 3-We have taken certain steps to implement recommended guidance and protocols for slowing the transmission of COVID-19, including, without limitation, the access/use restrictions set forth above. The undersigned acknowledges and agrees that we may revise those procedures at any time based on updated guidance and protocols and further agrees to comply with the revised procedures prior to utilizing our facilities, services, or programs (other than any online services). In further consideration of being permitted to enter our facility for any purpose including, but not limited to, observation or use of facilities or equipment, or participation in any on-site program, the undersigned hereby agrees to the following: A- The undersigned, on his or her behalf, and on the behalf of such participating children, hereby releases, waives, discharges, and covenants not to sue Port City Brazilian Jiu Jitsu, its directors, officers, employees, volunteers and agents from all liability to the undersigned or such participating children for any loss or damage, and any claim or demands on account of any property damage or any injury to, or an illness or the death of, the undersigned or such participating children (or any person who may contact COVID-19, directly or indirectly, from the undersigned or such participating children) whether caused by negligence, active or passive, of Port City Brazilian Jiu Jitsu or otherwise while the undersigned or such participating children are in, upon, or about the premises. B- The undersigned hereby agrees to indemnify and save and hold harmless Port City Brazilian Jiu Jitsu, its directors, officers, employees, volunteers and agenda, and each of them, from any loss, liability, damages or costs they may incur, whether caused by the negligence, active or passive, or otherwise while the undersigned or any participating child is in, upon, or about the premises of Port City Brazilian Jiu Jitsu. I HAVE CAREFULLY READ AND VOLUNTARILY SIGN THIS ASSUMPTION OF RISK, RELEASE AND WAIVER OF LIABILITY, AND INDEMNITY AGREEMENT AND FURTHER AGREE THAT NO ORAL REPRESENTATIONS, STATEMENTS OR INDUCEMENT APART FROM THE FOREGOING WRITTEN AGREEMENT HAVE BEEN MADE. I AM AWARE THAT BY AGREEING TO THIS AGREEMENT, I AM GIVING UP VALUABLE LEGAL RIGHTS, INCLUDING THE RIGHT TO RECOVER DAMAGES FROM Port City BRAZILIAN JIU JITSU IN CASE OF ILLNESS, INJURY, DEATH OR PROPERTY LOSS OR DAMAGE, INCLUDING, FOR THE AVOIDANCE OF DOUBT AND WITHOUT LIMITATION, EXPOSURE TO COVID-19 AND ANY ILLNESS, INJURY, OR DEATH RESULTING THEREFROM. I UNDERSTAND THAT THIS DOCUMENT IS A PROMISE NOT TO SUE AND A RELEASE OF AND INDEMNIFICATION FOR ALL CLAIMS. IF SIGNING ON BEHALF OF A MINOR, I ALSO UNDERSTAND THAT THIS AGREEMENT IS MADE ON BEHALF OF MY MINOR CHILD(REN) AND/OR LEGAL WARDS AND I REPRESENT AND WARRANT THAT I HAVE FULL AUTHORITY TO SIGN THIS AGREEMENT ON BEHALF OF SUCH MINOR(S).