Women in Government Self Defense Workshop Registration

Student first name

Student Last name

Student Date of Birth

Student Email Address

Student Street Address

City

State

Zip Code

Student Phone number

Employer or school you attend

How did you hear about this workshop?

Parent/Guardian name if applicable

Parent/Guardian email

Parent/Guardian phone

Emergency Contact name

Relationship to emergency contact

Emergency Contact phone number

Emergency Contact alternative phone number

Please describe any medical conditions that we should be made aware of:

Waiver / Release/ Assumption of Risk - By typing "yes" and checking each box below I hereby agree and acknowledge the following terms:

This program is being offered by the Town of Leesburg as the sponsor. The Town has chosen Mastery Jiu-Jitsu as its instructor.

I have been advised that the martial art known as "Jiu-Jitsu" is taught using precautions to avoid any injuries. However, participation in the Mastery Jiu-Jitsu classes carries with it certain inherent risks and dangers that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks range from minor injuries such as scratches, bruises, and sprains, to major injuries such as eye injury or loss of sight, joint or back injuries, heart at-tacks, and concussions, to catastrophic injuries including paralysis and death.

The practice of Jiu-¬Jitsu presents a risk of skin infections, MRSA, transmittable diseases, bacteria(s) and viruses, including, but not limited to, COVID-19.

I shall not attend Mastery Jiu-Jitsu classes if I am diagnosed with COVID-19 or if I am in close contact with some-one diagnosed with COVID-19. Further, if I am displaying symptoms of COVID-19, or if I am in close contact with someone who is displaying symptoms of COVID-19, I shall not attend Mastery Jiu-Jitsu classes. Symptoms of COVID-19 can range from mild illness to pneumonia, including fever, respiratory symptoms such as coughing, sore throat and/or shortness of breath, and other symptoms such as a runny nose, headache, muscle or joint pains, nausea, diarrhea, vomiting, loss of sense of smell, altered sense of taste, loss of appetite and fatigue. If I am displaying these symptoms when in attendance at Mastery Jiu-Jitsu classes, I acknowledge that I may be asked to leave.

Along with the possibility of personal injury, injury to property is also possible, including but not limited to, possible loss of wages and the ability to earn such wages.

I acknowledge that I have consulted with a physician, and I have no health problems that would preclude me from full and safe participation in Jiu-Jitsu.

With full knowledge and understanding of the aforementioned risks, both to myself and to my property, and after having these dangers fully explained to myself and/or to my legal guardian, I nevertheless desire to participate in Mastery Jiu-Jitsu training and activities.

Due to the nature of the activities conducted in Mastery Jiu Jitsu classes, it would be unreasonable for the Town of Leesburg, as sponsor, or Mastery Jiu-Jitsu LLC as instructor and/or the respective owners, directors and share-holders, agents and employees of either the sponsor or the instructor to be in any way responsible for my injury, contraction of any disease including but not limited to COVID-19 (or death) and to the full extent of the law I hereby waive my legal rights of action against and fully release the company for loss, damages, injury or death however arising out of or in relation to my participation in the activities for which I am registering conducted or organized by both the Town of Leesburg and Mastery Jiu-Jitsu including, without limitation, liability for any negligent or tortious act or omission, breach of duty, breach of contract or breach of statutory duty on the part of either the Town of Leesburg or Mastery Jiu-Jitsu, its office bearers, directors, employees or agents related to the program for which I am registering.

I have and will maintain appropriate medical insurance during classes/training. I authorize any emergency first aid, CPR, AEDs, medication, medical treatment, and/or emergency transportation and I assume all costs involved in such treatment.

I understand that the Town of Leesburg and Mastery Jiu-Jitsu reserves the right to refuse registration in this pro-gram to any individual who has been convicted of a sex crime.

I will not video record or photograph any classes/training without prior permission from Mastery Jiu-Jitsu.

L. I am also aware that for purposes of safety, security and quality control there are surveillance cameras mounted throughout Mastery Jiu-Jitsu. Furthermore, I understand and acknowledge that video recording or photographs may be taken of me during classes/training. I hereby grant the Town of Leesburg and Mastery Jiu-Jitsu LLC the unlimited use of my likeness in any format – photo, video, or other – for promotional advertisement or commercial use in any format known or yet to be developed in perpetuity, and I forfeit any form of payment.

I agree that if any term of this agreement is to any extent illegal, otherwise invalid, or incapable of being enforced, all other terms shall remain in full force and effect.

I understand that this agreement supersedes any and all previous oral or written agreements with regards to the practice of Jiu-Jitsu and I give up substantial rights by my acknowledgment and signature.

Student Signature

Guardian Signature for students under 18 years

Date

Women in Government Self -Defense Workshop Registration

Women in Government Self Defense Workshop Registration