Student Information *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

What class would you like to register for? *

Monday Gi

Monday MS Wrestling

Tuesday Nogi

Tuesday HS Wrestling

Wednesday Gi

Thursday ALL GIRLS

Thursday Nogi

Saturday Nogi

Family Information *

Mother's Name

First Name

Last Name

Father's Name

First Name

Last Name

Father's Phone *

(###)

###

####

EMERGENCY CONTACT INFORMATION *

First Name

Last Name

Phone *

(###)

###

####

*

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

OTHERE IS A 3.75% CREDIT CARD PROCESSING FEEption 2

No refunds after billing is complete.

We do not offer makeup classes.

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 my child

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

Print Name *

First Name

Last Name

Signed Name *

First Name

Last Name

Date *

MM

DD

YYYY