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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}

Wrestling Camp Waiver & Release of Liability

Location:

Gracie Jiu-Jitsu Summerlin

5375 S Fort Apache Rd

Las Vegas, NV 89148

Camp Dates:

JULY 20-25 , JULY 27 - 31

HOUR:

3:00PM - 4:00PM

Participant Information

Participant Name: {name}

Date of Birth: {dob}

Parent / Guardian (if under 18): {name}

Phone: {phone}

Email:

Emergency Contact

Name: {contact_name}

Relationship:  {contact_relation}

Phone: {phone}

Assumption of Risk

I   {name}  understand that participation in wrestling activities at Gracie Jiu-Jitsu Summerlin may include physical drills, takedowns, conditioning exercises, and live sparring.

I {name}  understand that these activities carry inherent risks, including but not limited to physical injury. I voluntarily assume all risks associated with participation in this program.

Release of Liability

I {name} hereby release and hold harmless Gracie Jiu-Jitsu Summerlin, its owners, instructors, coaches, staff, and volunteers from any and all liability, claims, demands, or causes of action arising from participation in the Wrestling Camp, including claims of negligence, to the fullest extent permitted by law.

Medical Authorization

I {name}  certify that the participant is physically able to participate in wrestling activities.

In the event of injury or medical emergency, I authorize Gracie Jiu-Jitsu Summerlin staff to seek emergency medical treatment if necessary and accept responsibility for any medical expenses incurred.

Behavior & Safety

Participants agree to follow all academy rules and safety instructions provided by coaches and staff.

Gracie Jiu-Jitsu Summerlin reserves the right to remove any participant from the program for unsafe behavior without refund.

Photo / Video Release

I {name}  give permission for photos and videos taken during the event to be used for promotional purposes by Gracie Jiu-Jitsu Summerlin.

  Yes

  No

Refund Policy

Camp registrations are non-refundable unless otherwise stated.

Acknowledgment

I {name} confirm that I have read, understood, and voluntarily agree to this waiver.

Participant Signature

Parent/Guardian Signature (if under 18)

Date {sign_date}