Signup

To be signed by PARENT or GUARDIAN if the participant is under 18 years of age

I, understand, acknowledge and agree that:

1. Jiu-Jitsu, mixed martial arts and other forms of martial arts and fitness training are
strenuous activities involving physical contact and may also involve the practice of techniques
designed to subdue and control an opponent.

2. I understand that it is advisable that I have a medical examination by a qualified physician before
participating in martial arts or any other physical activity. I represent and warrant that I am fit to
participate in strenuous physical activities such as martial arts and have no physical disabilities
affecting or limiting my ability to do so.

3. No representations or warranties upon which I have relied have been made to me by any agent,
owner, instructor or representative of or anyone associated with Queens Jiu Jitsu LLC, ITCNY,
(including all parties doing business under the trade name or trademark “Queens Jiu Jitsu”) or Christopher Ryan Quinn or any of their respective affiliates, agents, successors or
assigns (collectively, the “Company”) regarding the safety of the practice of martial arts or any other
related physical activity.

4. I recognize, accept and assume all risk of injury associated with practicing, participating in,
traveling to or returning from any practice, class, seminar, lesson, competition or athletic event held
by, associated with, or sponsored by the Company. Without limiting the foregoing, I ASSUME ALL
RISKS KNOWN OR UNKNOWN ASSOCIATED WITH PRACTICING MARTIAL ARTS AND OTHER PHYSICAL ACTIVITY.

5. On behalf of myself, my successors, assigns, heirs, personal representatives and all persons
claiming by, through or under me, I hereby fully and forever release, waive, relinquish and discharge
the Company and its instructors, subsidiaries, affiliates and all past and present employees, officers,
directors, shareholders, managers, members, agents, nominees, attorneys, successors and assigns
(collectively, the “Company Parties”) from any and all claims, losses, liabilities or demands of any
nature whatsoever in law or in equity, for injury or death to me regardless of whether arising during
or after my membership or participation in the activities of the Company when directly or indirectly
arising out of or resulting from any instruction, training, practice, class, seminar, lesson, competition
or event of the Company, including, without limitation, traveling to, participating in or returning from
any such event.

6. I shall hold harmless, defend and indemnify the Company Parties from and against any and all
claims, losses, liabilities or demands (including, without limitation, attorney’s fees) regardless of
whether arising during or after my membership or participation in activities of the Company, when
directly or indirectly arising out of or resulting from my acts or omissions in connection with the
practice, instruction or use of or participation in the martial arts or the activities of the Company.

7. I hereby grant to the "Company and its assigns the irrevocable right and permission, to use,
reuse, publish and republish, and otherwise reproduce, modify and display my name and/or the
Iikeness(es) of me, with or without other persons, that are included in any photograph(s), video(s),
artistic rendering(s) or other representations that the Company will make, has made, has had made
or has otherwise obtained, to copyright the same, in its own name or otherwise, in whole or in part,
individually or in conjunction with likenesses of other persons, and in conjunction with any
copyrighted or copyrightable matter, in any and all print, electronic, digital and other media now or
hereafter known, for use, distribution, advertisement, publication, promotion, merchandising, and
commercial exploitation in any medium, whether now known or hereafter created; and to use my
name in connection therewith if the Company so chooses.

8. Any controversy or claim arising out of or relating to this contract or any future contract, or the breach thereof, shall be settled by arbitration administered by the American Arbitration Association in accordance with its Commercial [or other] Arbitration Rules, and judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof.

9. I understand and agree that my participation in any classes, lessons, practice, training,
competitions or events held or sponsored by the Company is expressly conditioned upon my
agreement to the foregoing terms and conditions. I understand and agree that this Release and
Indemnity, among other things, releases the Company from responsibility for my injuries or death
and makes me responsible for injuries to or death of others caused by me.

Student Name: {name}

Parent or Legal Guardian of Minor, if Applicable (if not, put "N/A"):

Date: {sign_date}

Phone Number: {phone}

Birth Date: {dob}
Address: {address}