Lehi Jujitsu Membership Application
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Name *
Birthdate *
Address
Phone
Email *
Preferred contact method *
Required
Preferred payment method
Emergency Contact Name *
Emergency Contact Phone *
Emergency Contact Relationship *
How did you hear about our Martial Art school? *
I give permission to post photos and or video of self and or dependents on social media sites *
Required
Class Selection
Select only if the individual is the first member of the family attending or an additional family member
Toddler Class (Age 2-4)
Youth Class (Age 5-11)
Adult Class (Age 12 and up)
Personal Training
1st Family member
Additional family member
Number of Classes
Toddler Class (Age 2-4)
Youth Class (Age 5-11)
Adult Class (Age 12 and up)
Personal Training
1 class per week
2 classes per week
Specific Classifications
Clear selection
“In consideration of this application and participation in activities at Lehi Jujitsu Martial Art School (Yama No Onsen Kan) located at 68 West Main Street, Lehi, Utah, I agree for myself, heirs, successors and assigns to waive and release all liability, to not file any lawsuit or any other action, and to indemnify and hold harmless Sensei Duane Sheely, Lehi Jujitsu Martial Art School (Yama No Onsen Kan), instructors or members of the school for any injury or other legal cause of action arising out of the study or practice of any activity taught, practiced, or conducted in connection with my presence in the building. This waiver, release and indemnity includes, but is not limited to, injuries or any other legal cause of action occurring in classes, demonstrations, competitions or otherwise, and I waive and release any and all claims or rights that I may have in any jurisdiction for any liability arising out of any legal cause of action, including but not limited to, any liability from negligence, and I agree to indemnify and hold harmless the parties listed in the prior sentence. I understand that the study and practice of martial arts in general is an inherently dangerous activity and may lead to serious and permanent physical injury and/or death. Intending to be legally bound by my signature below, I acknowledge the above and for all time knowingly and voluntarily assume any and all risks associated with the study of martial arts or any other activities. Sensei Duane Sheely reserves the right to suspend any individual at any time. I have read this waiver, and I agree to adhere to the rules and standards of Lehi Jujitsu Martial Art School (Yama No Onsen Kan).” *
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I agree the information provided is accurate and correct and this checkbox and application submission constitutes my signature. *
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