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Team Rodrigo Vaghi-Omaha North Brazilian Jiu Jitsu
Online Student Registration
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STUDENT INFORMATION
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Emergency Contact Information
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Payment Option
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*WAIVER RELEASE AND ASSUMPTION OF RISK Please read carefully. This document
affects your legal rights. PRINT NAME AT TOP, SIGN AT BOTTOM.*
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I
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do hereby submit my application for participation in Brazilian Jiu Jitsu training located at the Edmunson
Youth Outreach Center, 4401 1/2 Fontenelle Blvd, Omaha, NE 68104, Omaha, Nebraska. I hereby assume
full responsibility and liability for all damages, injuries and losses that I may sustain or incur while
participating in or watching the training at the facility.
I realize that serious injury is commonplace in martial arts training such as what I am hereby participating;
and that even death is a very real possibility. I also realize that if i am injured, I might be disfigured,
disabled and/or rendered unable to work again. I realize that regardless of how the consequences might
occur – whether it be the result of an opponent’s actions, the action or inaction of a instructor(s), the
condition of the mats used, the conduct of a non-partcipant or some other reason – By entering into this
agreement I accept the risk of entering and being present at the training facility and give up and waive all
claims I or anyone acting on my behalf or through me might have against D.L. Taylor Enterprises LLC, the
promoters, operators, sponsors, officials, participants, non-participants, or the Edmunson Youth Outreach
Center and their agents, employees and representatives for any injury regardless of its nature, effect or
affect on me as a result of my participation and/or presence at the training facility.
I authorize, and agree to hold harmless, whatever medical personnel that may be present at the training
facility to take any action necessary, should I become injured.
I further understand that news media and others might cover this training and that it may also be
videotaped or otherwise shown to audiences around the world. I hereby consent to having my likeness
shown, publicized, commented and/or reported on; and I do not expect to, and in fact waive any
compensation I might otherwise be entitled to as a result thereof.
I represent that I am in good health; that I am not presently, nor will I participate while under the influence
of any drug or medication; that no one affiliated with this training facility has encouraged me to enter or
made any representations regarding my fitness or ability to participate; that I have read and understood
every provision of this release; and that I am legally competent to and freely enter into this waiver, release
and assumption of risk agreement.
____________________________________
SIGNATURE (check box for electronic signature)
I am a Parent/Guardian and competitor is a juvenile
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A "request for payment" will be sent to the student via Paypal for fees. Upon
PAYMENT the registration process is complete. Please keep a copy of any payments.
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