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{name}, {dob} 

{contact_name}, {contact_phone}, {contact_relation}

I, the undersigned, hereby waive all claims against all persons associated with Silverback Brazilian Jiu-Jitsu Huntsville. I understand that I am participating in a Martial Art which has body contact. I understand that this form of Martial Arts involves choke holds, arm locks, neck cranks, throws, slams, accidental punches, kicks, elbows, knees and such which could potentially cause serious injury or even death. I assume full responsibility for all my actions during and connected to the above organization. I understand the risk of participating in this form of Martial Arts training and hereby release Silverback Brazilian Jiu-Jitsu Huntsville  and all of its agents, employees and associates of and from any and all liability, claims, demands, actions, medical bills, and causes of action whatsoever arising out of or relating to any negligent or other act or omission, and/or any loss, damage or injury, including death, that may be sustained by the undersigned or any property of the undersigned in participating in this form of training. I, The Undersigned, also state that I (or my son or daughter) am in good physical condition and know of no reason why I (they) cannot participate in this form of training. I understand that in case of emergency, I hereby authorize any licensed medical personnel to perform any accepted medical assistance deemed necessary and I agree to bear the expense of any such treatment. As additional consideration for participating in this training, I agree that my attendance and/or performance at the event and abroad at events and such may be photographed, filmed and/or taped and used by Silverback Brazilian Jiu-Jitsu Huntsville for marketing purposes and I authorize the use of my image and I waive any compensation thereof-even if I discontinue my participation with Silverback Brazilian Jiu-Jitsu Huntsville. I acknowledge that I would like to receive correspondence from Silverback Brazilian Jiu-Jitsu Huntsville via telephone, mail and email. I, the undersigned, being duly aware of the risks and hazards inherent upon participating in this form of Martial Arts agree to all its rules, terms and conditions. I acknowledge that I have received a copy of the Silverback Brazilian Jiu-Jitsu Huntsville rules, have read them, understand them, and agree to honor and obey them. I understand that disobeying the rules may, at Silverback Brazilian Jiu-Jitsu Huntsville’s discretion, result in suspension, disqualification, and/or expulsion from Silverback Brazilian Jiu-Jitsu Huntsville, and that I will not be entitled to a refund of fees/sponsorship compensation, and if expelled must pay the remainder of my contract/agreement if one has been signed. In signing the foregoing release, the Undersigned hereby acknowledges and represents that he/she has read the foregoing release understands it and signs it voluntarily; that he/she is over 18 years of age and of sound mind. If under 18 years of age, parent/legal guardian in signing this release agrees to all its terms and conditions.

, {sign_date}