Student Registration Form

Please answer all questions that apply; for questions do not apply, please print “N/A” in the space provided. Please keep us informed of
any changes. Please present identification at the time of submitting this form. Thank you!!

� Mr. � Ms. � Mrs. First: _______________________________Last:_________________________________________

Address_______________________________________________________________________________________
City: _____________________________ State/Province: ___________ Zip/Postal Code:________________________
IF A BUSINESS ADDRESS Indicate Company Name: ___________________________________________________
Country: CIRCLE ONE: •USA •Canada •Mexico •Other: ______________________________________
Home: ( ) __________________ Work: ( )_________________ ext: ___ Mobile :( )___________________
FAX: ( ) ______________________ E-mail (required):________________________@____________________
Birth date (i.e. 05/10/1972):___________________ Height_______ Weight ________ GI SIZE: ________ (office use only)
Marital Status: •Single •Married •Other Driver’s License OR ID #:________________________
Occupation: _________________________________ Employer/School Name: ___________________________________
How did you hear about us: _____________________________________________________________________________
Is the person a student at this location? �Yes � No Referring Students Name: ___________________________________
Emergency Contacts: Name: __________________________________ Relationship: _________________________
Home: ( ) _____________________Work: ( ) _______________________Cell: ( ) ______________________
Special Medical Conditions: ______________________________________________________________________________

(Office Use Only)

Introductory Class Scheduling Process SLOT Enrollment Process Continued Completed By
Confirmation Confirmation For Group Class Students
Inquiry Attended?
Intro Date Call Day of Caller Completed Standard TA  Initial: Date:
Date Yes or No
Week Initials Gave them Copy of Agreement 
Highlighted and Reviewed Dates 
Gave them Gi (Group Students Only) 
Gave them Schedule & GI Sheet 
10 Day Trial Starts On:
10 Day Trial Ends On:
Entered Into MAS 
Penny Out Trial Gi/Charge Emb GI 
Printed BQC 
Notes
2 Moved to Slot 3G
For Private Class Students
Completed Short Term TA
Process Payment for Gi 
Process Package Payment in Full 
Gave them General Info Sheet 
Entered Into MAS
SLOT Enrollment Process Completed By
Printed Private Class Card
Check the Box and Move on Printed BQC
Instructor? Notified 
Moved to Slot 3P
Initial:
Completed Registration Form  Trial Period in Progress Initial: Date:
Gave E-Mail Address Date: Trial Complete and Enrolled 
1S Signed the Waiver 
3G Issue Referral Credit (if Any) 
Took Intro Class  Verified Billing Setup in MAS
Entered information into MAS  Moved to Slot 4
Moved to Slot 2 

Completed Registration Form  Initial: For Private Class Students

Gave E-Mail Address
Signed the Waiver  Date:
3P Classes Officially Started  Initial: Date:

1W Took Intro Class 

Moved to Slot 4 

Entered information into MAS  Initial: Date:

Moved to Slot 2  4 Filed Documents 
 PLEASE READ CAREFULLY
THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS
WAIVER / RELEASE / ASSUMPTION OF RISK
I understand and have had explained to me that the martial art known as “Gracie Jiu-Jitsu is taught using all
precautions to avoid any injuries. However, it may entail some risk of accident or injury and that this may be
serious or even mortal as a consequence of the practice of the before mentioned “Gracie Jiu-Jitsu.”

I understand and have had explained to me that, along with the possibility of personal injury, injury to property is
also possible, such as, but not limited to possible loss of wages and the ability to earn such wages.

With full knowledge of the aforementioned dangers, both to my person and to my property (current and future),
and after having these dangers fully explained to myself and/or to my legal guardian:
_______________________ (Name of Legal Guardian)

I hereby certify and declare that I will release and forever hold free and discharge from any liability Jorge
Balares, and/or Luke Kovach “dba” Gracie Jiujitsu – San Dimas and each of their agents, stockholders,
directors, officers, employees and representatives of and from all claims, demands, rights and causes of action
of any nature whatsoever which may have or which may hereafter accrue to me, arising from and by reason of
any and all bodily or personal injury, damage to property or other loss and any consequence thereof, whether
known or unknown, seen or unforeseen, resulting from my participation in Gracie Jiu-Jitsu and other programs
offered by Gracie Jiujitsu - San Dimas, their persons and entities mentioned above.

Further, knowing and understanding these risks, nevertheless I hereby agree to voluntarily assume these risks
and to release and hold harmless all the persons or entities mentioned above whom might otherwise be liable to
me for damages. It is further understood that this waiver, release and assumption of risk is forever binding on
my heirs and assigns. I also understand and acknowledge that I have and will maintain appropriate medical
insurance during classes/training.

I am also aware that for purposes of safety, security and quality control there are surveillance cameras mounted
throughout the Gracie Jiujitsu - San Dimas. Furthermore, Because of the popularity of the Gracie University, I
understand and acknowledge that often times filming, video or photographs may be taken of me during
classes/training. I hereby grant Gracie Jiujitsu - San Dimas the unlimited use of my likeness in any format
video/DVD for promotional advertisement or commercial use in any format know or yet to be developed in
perpetuity and I forfeit any form of payment. It is further understood that I will not film any classes/training
without prior permission from Gracie Jiujitsu - San Dimas.

My signature on this document is evidence that I know and understand and have had this document explained
to me, that I fully understand the dangers that are inherent in this martial art and that I voluntarily certify that I
will not hold Jorge Balares, and/or Luke Kovach “dba” Gracie Jiujitsu – San Dimas, Brajitsu, Inc., d.b.a. Gracie
Jiu-Jitsu University, Rorion Gracie, the Gracie family, their agents and/or assigns, responsible for any injury
whether as a result of training or not.

In addition, I agree to the policies applied for all students of Jorge Balares, and/or Luke Kovach “dba” Gracie
Jiujitsu – San Dimas presented at the time of registration and future changes implemented.

PRINT NAME: ________________________ SIGNATURE: __________________________

Guardian Name: _____________________ Guardian Signature: ________________________

(Guardian Signature required if student is less than 18 years old)

Date: ___________