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Lucas Lepri Brazilian Jiu Jitsu & Fitness 

Waiver and Release of Liability 

Dated: May 24, 2018

I hereby enroll for Martial Arts training classes with Lucas Lepri Brazilian Jiu Jitsu & Fitness, at 1636 Sardis Rd North Suite A-170, Charlotte, NC 28270.

In consideration for being permitted to participate in Martial Arts training and all other related activities conducted by Lucas Lepri Brazilian Jiu Jitsu & Fitness, I, myself, my spouse, legal representatives, heirs and assigns, hereby release, waive and discharge Lucas Lepri Brazilian Jiu Jitsu & Fitness, its administrators, 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 there from, on account of injury to my person, property, even injury resulting 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 Lucas Lepri Brazilian Jiu Jitsu & Fitness, located 1636 Sardis Road North Suite A-170, Charlotte, NC 28270. 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 Lucas Lepri Brazilian Jiu Jitsu & Fitness and or while participating in Martial arts.

I agree to indemnify the releases and hold them each harmless from any and all loss, liability, damage or cost they may occur due to my presence at Lucas Lepri Brazilian Jiu Jitsu & Fitness 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 are no physical or mental defects that would endanger my well-being or that of other participant 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 the State of North Carolina 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.

First Student's Name

First Name*

Last Name*

Phone*
First Student's Date of Birth*
First Student's Information
If Adult: Current belt rank
If Minor: Current belt rank
First Student's Signature*
Second Student's Name

First Name*

Last Name*
Second Student's Date of Birth*
Second Student's Information
If Adult: Current belt rank
If Minor: Current belt rank
Third Student's Name

First Name*

Last Name*
Third Student's Date of Birth*
Third Student's Information
If Adult: Current belt rank
If Minor: Current belt rank
Fourth Student's Name

First Name*

Last Name*
Fourth Student's Date of Birth*
Fourth Student's Information
If Adult: Current belt rank
If Minor: Current belt rank
Fifth Student's Name

First Name*

Last Name*
Fifth Student's Date of Birth*
Fifth Student's Information
If Adult: Current belt rank
If Minor: Current belt rank
Sixth Student's Name

First Name*

Last Name*
Sixth Student's Date of Birth*
Sixth Student's Information
If Adult: Current belt rank
If Minor: Current belt rank
Seventh Student's Name

First Name*

Last Name*
Seventh Student's Date of Birth*
Seventh Student's Information
If Adult: Current belt rank
If Minor: Current belt rank
Eighth Student's Name

First Name*

Last Name*
Eighth Student's Date of Birth*
Eighth Student's Information
If Adult: Current belt rank
If Minor: Current belt rank
Ninth Student's Name

First Name*

Last Name*
Ninth Student's Date of Birth*
Ninth Student's Information
If Adult: Current belt rank
If Minor: Current belt rank
Tenth Student's Name

First Name*

Last Name*
Tenth Student's Date of Birth*
Tenth Student's Information
If Adult: Current belt rank
If Minor: Current belt rank
11 Student's Name

First Name*

Last Name*
11 Student's Date of Birth*
11 Student's Information
If Adult: Current belt rank
If Minor: Current belt rank
Student's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
How did you hear about us?
How did you hear about us?*

Referral ? (First and last name)

Other (Please explain)
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (under 18 years old) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
If Adult: Current belt rank
If Minor: Current belt rank
Parent or Guardian's Signature
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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