Employee Name:
                                                                                                     Classes Joined:
                                                                                                     Amount Paid:

Last Name_______________________________First______________________Middle__________________
Address________________________________City_______________________State______Zip________
Home Phone ( )________________ Cell Phone ( )_________________
DOB___/___/___ Male_____ Female_____ Age______ HT_____ WT_______
Email____________________________________________________________________________________
Styles interested in taking: Muay Thai Kickboxing___ No GI Jiu Jitsu/Submission Grappling___ Jiu-Jitsu___
MMA Pro Cage Fighting Team___ Boxing___
Have you ever failed a medical exam? Yes_____ No_____ If yes, for what
reason_____________________________________________________________________________________
__________________________________________________________________________________________
If you are handicapped, and wish to be identified as such, list any limitation, physical or mental, which may affect your ability to perform or participate as a member.____________________________________________________
_________________________________________________________________________________________
Have you ever had: Broken bone_________ Concussion____________ HIV Positive____________
Asthma___________ Blackouts__________ Back Trouble___________ Epilepsy_____________
Other_____________________________________________________________________________________
EXPERIENCE IN MARTIAL ARTS
School, System or Style_________________________________________________ How Long______________
Your Rank________________________ Other System or Styles:_______________________________________
Reason for Leaving Former School______________________________________________________________
Describe your goal in the Martial Arts____________________________________________________________
_________________________________________________________________________________________
Describe your reason for enrolling_______________________________________________________________


Jones County Combat
Release and Waiver of Liability and Indemnity Agreement
(Read Carefully Before Signing)
In consideration of being permitted to participate in any way in the Martial Arts Program indicated below and/or being
permitted to enter for any purpose any restricted area (here in defined as any area where in admittance to the general
public is prohibited), the parent(s) and/or legal guardian(s) of the minor participant named below agree:
1. The parent(s) and/or legal guardian(s) will instruct the minor participant that prior to participating in the below
martial arts activity or event, he or she should inspect the facilities and equipment to be used, and if he or she believes
anything is unsafe, the participant should immediately advise the officials of such condition and refuse to participate. I
understand and agreed that, if at any time, I feel anything to be UNSAFE, I will immediately take all precautions to
avoid the unsafe area and REFUSE TO PARTICIPATE further.
2. I / WE fully understand and acknowledge that:
(a) There are risks and dangers associated with participation in martial arts events and activities which could
result in bodily injury partial and/or total disability, paralysis and death.
(b) The social and economic losses and/or damages, which could result from these risks and dangers
described above, could be severe.
(c) These risks and dangers may be caused by the action, inaction or negligence of the participant or the
action, inaction or negligence of others, including, but not limited to, the Releasees named below.
(d) There may be other risks not known to us or are not reasonably foreseeable at his time.
3. I / WE accept and assume such risks and responsibility for the losses and/or damages following such injury,
disability, paralysis or death, however caused and whether caused in whole or in part by the negligence of the Releasees
named below.
4. I / WE HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the martial arts facility used by the
participant , including its owners, managers, promoters, lessees of premises used to conduct the martial arts event or
program, premises and event inspectors, underwriters, consultants and others who give recommendations, directions,
or instructions to engage in risk evaluation or loss control activities regarding the martial arts facility or events held at
such facility and each of them, their directors, officers, agents, employees, all for the purposes herein referred to as
“Releasee”...FROM ALL LIABILITY TO THE UNDERSIGNED, my/our personal representatives, assigns, executors, heirs
and next to kin FOR ANY AND ALL CLAIMS, DEMANDS, LOSSES OR DAMAGES AND ANY CLAIMS OR DEMANDS
THEREFORE ON ACCOUNT OF ANY INJURY, INCLUDING BUT NOT LIMITED TO THE DEATH OF THE PARTICIPANT
OR DAMAGE TO PROPERTY, ARISING OUT OF OR RELATING TO THE EVENT(S) CAUSED OR ALLEGED TO BE
CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE RELEASEE OR OTHERWISE.
5. I / WE HEREBY acknowledge that THE ACTIVITIES OF THE EVENT(S) ARE VERY DANGEROUS and involve the risk
of serious injury and/or death and/or property damage. Each of THE UNDERSIGNED also expressly acknowledges
that INJURIES RECEIVED MAY BE COMPOUNDED OR INCREASED BY NEGLIGENT RESCUE OPERATIONS OR
PROCEDURES OF THE RELEASEES.
6. EACH OF THE UNDERSIGNED further expressly agrees that the foregoing release, waiver, and indemnity agreement
is intended to be as broad and inclusive as is permitted by the law of the Province or State in which the event is
conducted and that if any portion is held invalid, it is agreed that the balance shall, notwithstanding continue in full
legal force and effect.
7. On behalf of the participant and individually, the undersigned partner(s) and/or legal guardian(s) for the minor
participant executes this Waiver and Release. If, despite this release, the participant makes a claim against any of the
Releasees, the parent(s) and/or legal guardian(s) will reimburse the Releasee for any money which they have paid to the
participant, or on his behalf, and hold them harmless.
8. Jones County Combat is not responsible for any lost or stolen items.

I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT,
FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE
BEING MADE TO ME AND INTEND MY SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL
LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.
Martial Arts School:  Jones County Combat
Participant Signature_____________________________________ Date:__________________
Parent or Guardian Signature (if minor) _____________________________________

Printed Name of Participant_______________________________________________
Address of Participant_____________________________________________________________________________________
Received by_______________________________________________________________________________________________
AMMA Signature Printed Name Member # Region on File Date
Privacy Release
I, ____________________, do hereby grant Jones County Combat and any assigns,
licensees, and legal representatives of Jones County Combat, the irrevocable right
to use my name (or any fictional name), picture, portrait, or photograph in all forms and media in
all manners, including composite or distorted representations, for advertising, trade, or any other
lawful purposes, and I waive any right to inspect or approve the finished version(s), including
written copy that may be created in connection therewith. I am of lawful age and or I am the
legal guardian of the above named. I have read this release and am fully familiar with its
contents.



______________________________                   ______________________________
      Grantor or Legal Guardian                                           Jones County Combat

______________________________                   ______________________________
                  Address                                                                    Address






Monthly membership fees are due in the amount of $25.00 at the 1St of each month. If a new member joins in between the 1st and the 15th of the month the fee will remain $25.00. If the new member joins from the 16th to the 31st the first months fee will be $15.00 and will return to the standard rate of $25.00 at the beginning of the next month. We do offer a discounted fee of $125.00 for 6 months and $230.00 for a full year.

Members that are under 18 years of age and are still enrolled in an educational program must maintain a current grade point average of no lower than a 2.0 or a C average in all of their current classes or they will not be allowed to participate in any of the training classes until their grades once again meet the requirements of this agreement.

All Members are expected to participate to the best of their ability in all activities of the class without disrespectful or demeaning behavior to any member of the class.

Fighting inside or outside of the Jones County Combat center will not be tolerated unless it is in a sparring session, self defense or at a scheduled sporting event with a willing combatant. Fighting outside of the center may result in loss of membership with no reimbursement of any member ship fees.