ADULT registration

Please fill out the 2 FORMS below and hit submit for each.

You will receive a confirmation within 24 hours that your form has been received. At that time we will confirm the day/time and process payment information.

PART 1

STUDENT INFORMATION

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

MM

DD

YYYY

How many days a week would you like to attend?

EMERGENCY CONTACT INFORMATION

First Name

Last Name

Relationship

Phone

(###)

###

####

PART 2

STUDENT INFORMATION

First Name

Last Name

I UNDERSTAND THERE WILL BE A SEPARATE FORM OF COMMUNICATION ABOUT PROCESSING MY CREDIT CARD PAYMENT

THERE IS A 3.75% CREDIT CARD PROCESSING FEE

No refunds after billing is complete. if you wish to cancel, please let us know 48 hours before your next billing cycle.

PHOTO/VIDEO PERMISSION

I agree that from time to time, that Greenwich Jiu Jitsu Academy will take photos and videos of its participants during program activities and events for use in educational or promotional materials in print, multimedia or web form. Please check the correct box if you give or do not give consent.

Yes, I give consent to use photos/videos of myself

No, I do not give consent to use photos/videos of myself

PRINT NAME

SIGNED NAME

Date

ADULT registration

PART 1

PART 2

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