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GRACIE SUMMERLIN LLC
STUDENT WAIVER 

Full Name: {name}
Date of Birth:  {dob}
Address:  {address}
Contact Information:
Cell Phone #: {phone}
Emergency contact: {contact_name} {contact_phone}  {contact_relation}

WAIVER – RELEASE FROM LIABILITY & INDEMINITY AGREEMENT
1. I, {name}, acknowledge that I have voluntarily agreed to participate in
martial arts/jiujitsu/grappling practice and instruction at Gracie Summerlin LLC, located at 5375 South
Fort Apache Rd, Suite 104, Las Vegas, NV 89148.
2. I understand that this type of sport may be inherently dangerous regardless of the level of supervision.
Injuries may occur due to the physical situations including a slippery floor surface, an overzealous
partner, or combination of any circumstances. It is clear to me that my voluntary participation in this
activity will expose me to risk of injury, and that any amount of time spent engaging in this activity only
makes it more likely that injuries will occur at some time.
3. I am voluntarily participating in these activities with knowledge of the danger involved and
hereby agree to accept all risks of injury or death and verify this statement by placing my initials
here: .
4. As a consideration for being permitted to engage in these activities, and to use the facilities provided by
Gracie Summerlin LLC, I hereby agree that I will not make a demand, a claim against, or sue Gracie
Summerlin LLC, its employees or authorized agents for any injury or damage resulting from negligence
or act howsoever caused because of my participation in martial arts/jiujitsu/grappling. I hereby release
Gracie Summerlin LLC, its employees and authorized agents from all actions claims and demands, that I
now have or may thereafter have for injury or damage resulting from my participation in martial
arts/jiujitsu/grappling.
Student/ Releaser’s Signature:
Date: {sign_date}
Parent or Legal Guardian’s Signature (if under 18):  {contact_name}
Date: {sign_date}

To cancel your membership at Gracie Jiu-Jitsu Summerlin, please provide a 30-day notice prior to your due date. The notification MUST be received by the billing department via the Gym Desk app. Simply log in to the Gym Desk app, which you have full access to as a member, go to the contact section, and write an email to the billing department asking for a cancellation or freeze.

Refund policy:

Any items purchased at the school are non-refundable. If you need to exchange for a different size, please see Professor Andre. Please note the item must be new and unworn.