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RELEASE & WAIVER OF LIABILITY
I {name} hereby waive all claims against Shannon Clark, Michael
Kehrle, Ricky Royce, Matthew Coletta, Ronald McMahon, and David Lu along with any and all
persons associated with the Harleysville BJJ/3G Jiu Jitsu Academy. I understand that I am
participating in a martial art which has body contact. I understand that this form of martial arts
involves choke holds, arm locks, neck cranks, ankle locks, throws, punches, kicks, elbows, knees,
and such, which could potentially cause serious injury or even death. I assume full
responsibility for all my actions during and connected to the above organization. I understand
the risk of participating in this form of martial arts training and hereby release Harleysville
BJJ/3G Jiu Jitsu Academy and all of its agents, employees and associates of and from any and all
liability, claims, demands, actions, medical bills, and causes of action whatsoever arising out of
or relating to any negligent or other act or omission, and/or any loss, damage, or injury,
including death, that may be sustained by the undersigned or any property of the undersigned
in participating in this form of training.
I, the undersigned, also state that I am in good physical condition and know of no reason why I
cannot participate in this form of training. I understand that in case of emergency, I hereby
authorize any licensed medical personnel to perform any accepted medical assistance deemed
necessary and I agree to bear the expense of any such treatment.
As additional consideration for training at the Harleysville BJJ/3G Jiu Jitsu Academy, I agree that
my attendance and/or performance at the academy and abroad at events and such may be
photographed, filmed and/or taped, and used by the Harleysville BJJ/3G Jiu Jitsu Academy for
marketing purposes and I authorize the use of my image and I waive any compensation thereof
– even if I discontinue my training at the Harleysville BJJ/3G Jiu Jitsu Academy.
I acknowledge that I would like to receive correspondence from Harleysville BJJ/3G Jiu Jitsu
Academy via telephone, text, mail, email and social media.
I, the undersigned, being duly aware of the risks and hazards inherent upon participating in this
form of martial arts agree to all its rules, terms, and conditions.
In signing the foregoing release, the undersigned hereby acknowledges and represents; that
he/she has read the foregoing release, understands it and signs it voluntarily; that he/she is
over 18 years of age and of sound mind. If under 18; parent/legal guardian in signing this
release agrees to all its terms and conditions.
STUDENT’S NAME - PRINT: {name}
PARENT/GUARDIAN NAME: {name}
(Parent/Legal Guardian if under 18 years of age)
STUDENT’S SIGNATURE:
(Parent/Legal Guardian if under 18 years of age

Date: {sign_date}