Farmington Martial Arts
110 W. Pine St • Farmington, MO 63640 • 573-760-1630
Name______________________________________________ Age_____
Address_____________________________________________ Gender____
City_______________ State______ Zip Code________ Phone ______________
Date of Birth _______ email _____________________________________
Physical Disabilities _____________________________________________
Academy_____________________________ Rank___________
Which seminar(s) would you like to attend:
Saturday Sept 28th
11:30am – 12:30pm kids (13 & under) $40 ____
1:00pm – 3:00pm adults $80 ____
Sunday Sept 29th
1:00pm – 3:00pm adults $80 ____
Do you need a Jiu-Jitsu gi? ____ ($90 white gi) size ____
If you order a uniform it will be waiting for you at the seminar
Uniform orders must be placed by September 1st
LEGAL WAIVER
I understand that there is a risk of personal injury involved in said course of instruction and with this
knowledge and in consideration of the privilege of participation in the activities of GMHMA, LLC. I agree
to indemnify and save harmless Royce Gracie, Ceth A. Jordan, his designated agents, and any
representative of GMHMA LLC from all losses caused by accident or injury to the Enrollee or to any
third persons who may be Enrollees of GMHMA, LLC in the event that either the Enrollee or said third
party is injured in any way, during the proper performance and execution of martial arts instruction which
includes any subsequent tournaments or other places of participation connected with the activities of,
GMHM LLC, Farmington Martial Arts. I further agree to wear all required safety equipment in
accordance with the rules.
Because of the physical demands of marital art instruction, I further understand that I must be in good
physical condition to participate in said instruction and hereby certify that I am in good physical condition
by signing the Enrollment Agreement below or by the signature of my parent or guardian.
I also understand that any photographs of me that are taken may be used for publicity without
compensation.
_________________________________
STUDENT SIGNATURE
___________________________________
SIGNATURE OF PARENT OR GUARDIAN (if minor)
_____/_____/_____
DATE
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