Student Application

Name: ______________________________________________________  Date of Birth: ______________________

Address: _________________________________ City: __________________State: ______ Zip: ________________

Home #: ____________________ Cell: ___________________ E-mail: ____________________________________

Emergency Contact  Name 1: ___________________________________ Phone #: ___________________________

Emergency Contact Name 2: ___________________________________  Phone #: ___________________________

Your interest in joining (    ) Fitness  (    ) Training  (    ) Other ___________ Prior MMA Experience: ____________

How did you hear about us? _______________________________________________________________________

All students are required to provide proof of age with a valid photo ID. Children are not to be left unattended after class. Parents must pick up their children inside the Academy once class is finished. Kids are not permitted to leave without their guardian present. Children are not permitted on or near the Exercise Equipment area. Any students that disrespect the rules of the Academy will have their membership suspended or revoked without refund. Parents will be held responsible for their children’s behavior and actions during their stay at our Academy. Our top priority is the safety and well being of all our members and guests. A copy of the Academy Rules is available in the front entrance.

Do you have any questions regarding the terms and conditions of Carvalho Academy? (Circle) Yes or No    Your Initials _____.

Has the academy representative answered all of your questions to your satisfaction? (Circle) Yes or No        Your Initials _____.

 Acknowledge and fully understand that I will be engaging in a contact sport that might result in serious injury, including permanent disability, and severe social and economic losses due not only to my own actions, inactions or negligence, but also to the actions, inactions, or negligence of others. Further, I acknowledge that there may be other risks not known to me or not reasonably foreseeable at this time.

 I have familiarized myself with the risk involved in the Judo, Jiu-Jitsu, Capoeira, Muay-Thai, Core Training, Nami Ryu and/or Carvalho Fitness Gym Equipment; I assume all such risks and accept personal responsibility.

Do you have any conditions which would affect your mental or physical ability to be a member of the Carvalho Academy? (Circle) Yes or No Your Initials __________.    

I have consulted with my medical physician and confirmed my mental and physical fitness to train. I also have medical coverage for any loss.  Initials __________.

 Release, waive, discharge and covenant not to sue the Carvalho Judo and BJJ Academy LLC; and Sensei Edson Carvalho Pinto, together with their affiliated clubs, their respective administrators, directors, agents, and other employees or volunteers of the organization, other participants, their parents, guardians, owners, lessors, and lessees of premises located at 85-99 Hazel Street in Paterson used as mixed martial arts training and fitness center, all of whom are hereinafter referred to as Releasees, from any and all claims, demands, losses or damages on account of injury, including permanent disability and or damage to property, caused or alleged to be caused in whole or in part by the negligence of the Releasees or otherwise to the fullest extent permitted by law.

I agree that, prior to participating, I will inspect the mats, equipment, facilities, competitors, conditions of the premises or of any equipment I choose to use, and if I believe anything is unsafe or beyond my capability, I will immediately advise Sensei, instructor, and/or supervisor of such conditions and refuse to participate. I further understand and discharge Carvalho Academy and/or Sensei Edson Carvalho for any injury, including permanent disability caused or alleged to be caused in whole or in part by any equipment I use during my training at Carvalho Academy.

I HAVE READ THE ABOVE WARNING, WAIVER AND RELEASE,  AND KNOWING THIS, SIGN IT VOLUNTARILY. I AGREE TO PARTICIPATE KNOWING THE RISKS AND CONDITIONS INVOLVED AND DO SO ENTIRELY OF MY OWN FREE WILL.

____________________________________    ____________________________________     ________________

Participant (Print Name)                     Participant’s Signature Date

FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE

(UNDER AGE 18 AT TIME OF REGISTRATION)

____________________________________     ____________________________________    _________________

Parent/Guardian (Print Name) Parent’s/Guardian’s Name Signature Date

Student Application

Name: ______________________________________________________  Date of Birth: ______________________

Address: _________________________________ City: __________________State: ______ Zip: ________________

Home #: ____________________ Cell: ___________________ E-mail: ____________________________________

Emergency Contact  Name 1: ___________________________________ Phone #: ___________________________

Emergency Contact Name 2: ___________________________________  Phone #: ___________________________

Your interest in joining (    ) Fitness  (    ) Training  (    ) Other ___________ Prior MMA Experience: ____________

How did you hear about us? _______________________________________________________________________

All students are required to provide proof of age with a valid photo ID. Children are not to be left unattended after class. Parents must pick up their children inside the Academy once class is finished. Kids are not permitted to leave without their guardian present. Any students that disrespect the rules of the Academy will have their membership suspended or revoked without refund. Parents will be held responsible for their children’s behavior and actions during their stay at our Academy. Our top priority is the safety and well being of all our members and guests. A copy of the Academy Rules is on the back of this form and is available in the front entrance. Please inform us if you would like a copy to take home.

Do you have any questions regarding the terms and conditions of Carvalho Academy? (Circle) Yes or No    Your Initials _____.

Has the academy representative answered all of your questions to your satisfaction? (Circle) Yes or No        Your Initials _____.

 Acknowledge and fully understand that I will be engaging in a contact sport that might result in serious injury, including permanent disability, and severe social and economic losses due not only to my own actions, inactions or negligence, but also to the actions, inactions, or negligence of others. Further, I acknowledge that there may be other risks not known to me or not reasonably foreseeable at this time.

 I have familiarized myself with the risk involved in the Judo, Brazilian Jiu-Jitsu, Cardio Kick Boxing, Core Conditioning, Fitness Training, Capoeira, Yoga, Pilates and/or Dancing; I assume all such risks and accept personal responsibility.  

Do you have any conditions which would affect your mental or physical ability to be a member of the Team Carvalho Academy? (Circle) Yes or No Your Initials __________.    

I have consulted with my medical physician and confirmed my mental and physical fitness to train. I also have medical coverage for any loss.  Initials __________.

 Release, waive, discharge and covenant not to sue the Carvalho Fitness, LLC; and Sensei Edson Carvalho, together with their affiliated clubs, their respective administrators, directors, agents, and other employees or volunteers of the organization, other participants, their parents, guardians, owners, lessors, and lessees of premises located at 505 Route 10, in Randolph used as mixed martial arts training and instructional fitness club, all of whom are hereinafter referred to as Releasees, from any and all claims, demands, losses or damages on account of injury, including permanent disability and or damage to property, caused or alleged to be caused in whole or in part by the negligence of the Releasees or otherwise to the fullest extent permitted by law.

I agree that, prior to participating, I will inspect the mats, equipment, facilities, competitors, conditions of the premises or of any equipment I choose to use, and if I believe anything is unsafe or beyond my capability, I will immediately advise Sensei, instructor, and/or supervisor of such conditions and refuse to participate. I further understand and discharge Team Carvalho Academy and/or Sensei Edson Carvalho for any injury, including permanent disability caused or alleged to be caused in whole or in part by any equipment I use during my training at Carvalho Academy.

I HAVE READ THE ABOVE WARNING, WAIVER AND RELEASE,  AND KNOWING THIS, SIGN IT VOLUNTARILY. I AGREE TO PARTICIPATE KNOWING THE RISKS AND CONDITIONS INVOLVED AND DO SO ENTIRELY OF MY OWN FREE WILL.

____________________________________    ____________________________________     ________________

Participant (Print Name)                     Participant’s Signature Date

FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE

(UNDER AGE 18 AT TIME OF REGISTRATION)

____________________________________     ____________________________________    _________________

Parent/Guardian (Print Name) Parent’s/Guardian’s Name Signature Date