Student's First Name: {first_name}
Home Address: {address}
Date of Birth: {dob}
Gender:
Home telephone number: {phone}
Email address:
Any Special Needs, Allergies or Medical conditions?
Any other items that you feel should be brought to the attention of the coaching team?
I give permission to Limerick BJJ Academy to include my child in club photograph’s
which will be used for promotional purposes on the club website, on the gym notice
board and in local papers. (please tick box if you agree to give permission).
I will ensure my child is dressed appropriately for class, i.e. wearing gi with belt, and
t-shirt/rashguard underneath, and long hair tied-up.
I will adhere to Limerick BJJ Academy code of conduct for children and parents.
I will inform the Coaches of any important changes to my child’s health, medication
or needs and also of any changes to the address or phone numbers given.
My signature hereunder confirms agreement with the above. In addition, I confirm that all details
are correct to the best of my knowledge.
Parent/Guardian:
Date: {sign_date}
Release of Liability - U18
I, hereby enroll for Martial Arts training classes with LIMERICK BJJ ACADEMY, at Unit 11, Ashbourne Business Park, Dock Rd, Courtbrack, Limerick, V94 WF83 Ireland.
In consideration for being permitted to participate in Martial Arts training and all other related activities
conducted by LIMERICK BJJ ACADEMY, I, myself, my spouse, legal representatives, heirs and assigns, hereby release, waive and discharge LIMERICK BJJ ACADEMY, Fergal Quinlan, its administrators, instructors. coaches, officers, directors ,volunteers and employees, other participants (the releases) and if applicable owners and lessors of the premises on which the activities take place, from all liability (whether known or unknown) to me, my spouse, legal representatives, heirs and assigns for any and all loss or damage and any claim for damages resulting therefrom, on account of injury to my person, property, even injury resulting in my death, whether caused by the negligence and/or gross negligence of the releases or otherwise while I am participating in said Martial Arts training or related activities. Furthermore I agree and covenant not to institute or prosecute, or allow to be instituted or prosecuted or in any way to aid in the institution or prosecution of any lawsuit or claim against LIMERICK BJJ ACADEMY, at Unit 11, Ashbourne Business Park, Dock Rd, Courtbrack, Limerick, V94 WF83, Ireland. I hereby assume full responsibility for the risk of bodily injury, death or
property damage due to the negligence of the release or otherwise while in or upon LIMERICK BJJ ACADEMY and or while participating in Martial arts. I agree to indemnify the releases and hold them harmless from any and all loss, liability, damage or cost they may occur due to my presence at LIMERICK BJJ ACADEMY premises whether caused by the negligence of the releases or otherwise. I will indemnify, save and hold harmless each of the releases from any litigation expenses attorney fees, loss, liability, damage, cost any release may incur as a result of such claim. I warrant I will not cause or attempt to cause any injury to myself or to any other participant, instructor or spectator I represent and warrant that I have consulted a licensed physician and that I am in good health and that there are no physical or mental defects that would endanger my well-being or that of other participants or instructor. I give permission, free of charge, with no promise, representation or expectation of compensation, to use any photos, pictures, media, likeness of him/her for advertisements, instructional videos in any medium or matter, online training programs, or marketing materials to promote martial arts sports, martial arts or fitness. I expressly agree that this release, waiver and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of Ireland and if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I represent and warrant that I have carefully read the foregoing release and waiver and understand the
contents thereof and sign this release as my own free act and further agree that no oral representations, statements or inducements apart from the foregoing written agreement have been made.
Parent(s) or court-appointed legal guardian(s) must sign for participating minor (those under 18 years of age)
Minor Name:
Date: {sign_date}
Parent/Guardian:
Parent/Guardian:
