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No.____________

VALENTE JIU-JITSU ACADEMY

PERSONAL INFORMATION (Please print this application and fill in all information clearly)

Name: ________________________________________________

Social Security No: ___________-________-___________

Address:_____________________________________________________________

Phone: (_____)______________________

City: _____________________________________ State: _______

Zip: ____________Country: _________________________

Birthday: _________/_________/_________ Height: ________________________ Weight: ___________________________

Email Address: __________________________________________

Occupation: _____________________________________

Is there an Official Representative Academy in your local area? YES___ NO___

If yes, please list the name of the Official Representative Academy: ________________________________________________

U.S. and Foreign applications: Please submits all applications to our U.S. Association Headquarters

PREVIOUS MARTIAL ARTS EXPERIENCE

Marital Art Style(s):______________________________________________________________

Rank Achieved: _____________________________________

Total Experience: Years (_________) Months (_______________)

Do you fight professionally? YES__ NO__

IN CASE OF EMERGENCY PLEASE CONTACT

Name __________________________________

Relationship ___________________Phone (_____) ____________________

MARTIAL ARTS ACADEMY OWNERS PLEASE FILL OUT THE FOLLOWING SECTION

Academy Name ____________________________________________

Date Business Started ________/________/_________

Address ___________________________________________________

Phone (_______) _____________________________

City _______________________________________ State__________ Zip_____________ Country ____________________

Number of Students ___________________________

Would you like to become an official representative? YES___ NO___

MEMBERSHIP BENEFITS

Personal Association Membership Card (includes ID number) applicant must supply two passport size photos (1 1/2" x 1 3/4").

Training under an Official Representative Academy set forth in the List of Representatives.

Each membership receives one Association Patch, T-shirt, and Sticker upon approval of application. (Does not include shipping cost).

Participation in exclusive Association events including seminars, tournaments, belt testing and training camps.

Participation, on temporary basis, in classes conducted by an official representative foreign or domestic (other than member's regular academy), without additional registration fees upon the presentation of a valid Association Membership Card.

Discounts on all open seminars and related classes upon the presentation of valid Association Membership Card.

MEMBERSHIP FEE

Annual membership fees are payable with application - $40.00 per member (all fees subject to change).

BELT TESTING

Belt testing requirements for all levels are available upon request.

Only instructors and full instructors who possess a Belt Test Certificate are allowed to conduct belt tests.

Upon testing for the rank of Black Belt, both Carlos Valente and the student's Instructor or Full Instructor must be present for the administration of the test.

Members are required to wear their Official Association Uniform or the Association Patch on their uniform when testing for their belt and during competitions.

Testing fees are due on or before the day of the Belt Test upon presentation of valid Association Membership Card.

If you do not receive your certificate within 30 days after passing your belt test, please contact the association headquarters.

ADULT’S BELT TESTING FEES

Blue Belt - $100 per member (includes testing, certificate and belt)

Purple Belt - $130 per member (includes testing, certificate and belt)

Brown Belt - $160 per member (includes testing, certificate and belt)

Black Belt - $350 per member (includes testing, certificate and belt)

CHILDREN'S BELT TESTING FEES

Yellow Belt - $50 per member (includes testing, certificate and belt)

Orange Belt - $60 per member (includes testing, certificate and belt)

Green Belt - $70 per member (includes testing, certificate and belt)

(All belt promotions are dependent on certain factors such as consistency, skill, attendance, and dedication.)

PARTICIPANT AGREEMENT, RELEASE AND WAIVER OF LIABILITY

RELEASE AND WAIVER OF LIABILITY

THIS DOCUMENT MAY AFFECT YOUR LEGAL RIGHTS.

PLEASE READ THE ENTIRE DOCUMENT CAREFULLY BEFORE SIGNING IT.

I, __________________________________________________________________, wish to participate in training and receive instruction in the art of Jiu-Jitsu from Carlos Valente. In consideration of the service provided to me by Carlos Valente, I hereby freely and knowingly accept and agree to the following terms and conditions:

Assumption of Risk: I understand that Jiu-Jitsu is a hazardous activity that involves inherent risks of serious physical injury. With full knowledge of risks involved in Jiu-Jitsu, I expressly assume all the risks of harm to myself arising from the practice of Jiu-Jitsu at the Valente Jiu-Jitsu Association.

Release of Claims and Waiver of Liability: I hereby expressly and for all times, on behalf of myself, my heirs, successors and assigns, executors and personal representatives release and agree to hold harmless Carlos Valente from any claim, demand or cause of action At law or equity from any injury to me that arises or might have arisen from my participation in the practice of Jiu-Jitsu, from my use of the equipment of the Valente Jiu-Jitsu Association or from may participation in any activity associated directly or indirectly with Carlos Valente Jiu-Jitsu Association, or from my use of Jiu-Jitsu techniques.

Indemnification : I hereby agree to indemnify and hold harmless Carlos Valente from any claim, demand or cause of action At law or equity, including, but not limited to, any claim of personal injury, that may be asserted against Carlos Valente by any third party as a direct or indirect result of my participation in the practice of Jiu-Jitsu, from my use of the equipment of the Carlos Valente Jiu-Jitsu Association, from my participation in any activity directly or indirectly associated with the Carlos Valente Jiu-Jitsu Association, or from my use of Jiu-Jitsu techniques.

Noncompetition: I hereby agree that, during my training and for a period of 1 year after I have ceased to train with Carlos Valente, I will not compete against the Valente Jiu-Jitsu Academy, Valente Jiu-Jitsu Association and his representatives, in any tournament or contest of Jiu-Jitsu, Gracie Jiu-Jitsu, Brazilian Jiu-Jitsu, or in any mixed martial arts tournament or contest in which the techniques of Gracie Jiu-Jitsu may be used.

Definition: As used in this agreement, the terms “Carlos Valente” and “Carlos Valente -Jitsu Association” include Carlos Valente, the Carlos Valente Jiu-Jitsu Academy, the Valente Jiu-Jitsu Association and any heir, successor, assign, executor, employee, member, representative, owner or director of any or all of them.

I HAVE READ THIS ENTIRE DOCUMENT. I UNDERSTAND AND AGREE TO ITS TERMS.

Signed: _________________________________________________________ Dated: ______/______/______

Printed Name: _____________________________________________________________________________

Signed: __________________________________________ Parent or Guardian (If signer is under the age of 18.)

IT IS STRONGLY RECOMMENDED THAT YOU CONSULT A PHYSICIAN BEFORE UNDERTAKING ANY PROGRAM OF STRENUOUS EXERCISE SUCH AS THE PRACTICE OF JIU-JITSU

PAYMENT INFORMATION (Foreign applications must pay in U.S. dollars)

CASH___CHECK___ *($20 service charge on all returned checks)

MONEY ORDER___

Total Due $_________________Date ______/______/______ Check / Money Order No. ______________________________

Name on Check / Money Order (please print) _________________________________________________________________

Please make all payments payable to Carlos Valente, and send along with the completed application to: 9888G Carmel Mountain Rd. San Diego, Ca 92129

* Law subject to a service charge of $20.00 or the maximum allows (Returned checks)

Please show proof of the following:

1) If you are applying for membership only please submits two passport size photos, copy of driver’s license or I.D. and present address.

2) If you are applying to become a representative, please submit proof of business, i.e. - business license and Tax I.D number.

OFFICE USE ONLY

Representative Name: _______________________________ Academy Name: ______________________________________

Membership Application No.: _________________________ Representative Application No.: __________________________

Member Since: _________/_________/_________

Comments:

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