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Waiver - Kioto BJJ South Shore
Waiver, Release and Acknowledgement of Risk (Please read carefully and completely before sending it back to us )
Sending us this Waiver means that the student or his/her parent or guardian agrees with all of its terms.
Email address *
PROGRAM *
STUDENT'S NAME *
Your answer
PHONE *
Your answer
ADDRESS *
Your answer
CITY *
Your answer
STATE *
Your answer
ZIP *
Your answer
D.O.B. *
MM
/
DD
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YYYY
EMERGENCY CONTACT (NAME/RELATIONSHIP/PHONE) *
Your answer
HOW DID YOU HEAR ABOUT US ? (If referred by someone please write his/her name) *
Your answer
Please tell us if the student has any injury, allergy or medical issue?
Your answer
WHICH DATE IS THE STUDENT COMING TO THE TRIAL CLASS ? *
MM
/
DD
/
YYYY
HOW MANY TIMES ON WEEK DO YOU PLAN ON TRAINING ? *
Special Offer ( New BJJ Adult students only )
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