Membership Agreement

Sandro Sampaio Brazilian Jiu-Jitsu Academy LLC
Carlson Gracie Team
Membership Agreement

Student Information

Name *

Date of Birth *

Age *

Gender *

Parent/Guardian (if under 18)

Address *

City *

State *

ZIP *

Phone *

Email *

Employer

Employer Address / Phone

Emergency Contact *

Relationship *

Emergency Contact Phone *

Terms of Contract

Sandro Sampaio Brazilian Jiu-Jitsu Academy LLC Carlson Gracie Team offers training in Brazilian Jiu-Jitsu, Muay Thai, Kickboxing, and MMA (Mixed Martial Arts). Competition in these sports is physical, tough, and competitive. Brazilian Jiu-Jitsu is a full contact sport and includes grappling, ground fighting, and self-defense.

If you have any physical or mental illnesses or injuries, are pregnant, have a history of heart trouble, stroke, high blood pressure, severe dizziness, diabetes, or other similar conditions, a doctor's permission in writing is required.

I am in compliance with the above and do not require a doctor's permission. *

Contract Term

Contract Start Date *

Contract End Date *

I agree to a six month contract beginning on the Start Date and continuing through the End Date.

I am bound to this contract for the entire six months except for military duty or deployment.

Cancellation: To cancel the contract for military duty or deployment, a copy of the military orders with deployment date is required for formal notification. The contract cancels 30 days from the date the academy receives the formal notification.

Billing: Tuition is billed monthly in advance on the first or fifteenth of each month, due and payable at the time of billing whether or not the student is attending classes.

Payments: This contract automatically renews on a month-to-month basis after the initial contract term unless the student gives a written request to cancel at least one month prior to the end of the six month contract.

Thirty days written notice is required for cancellation of the month-to-month renewal.

Declined or Delinquent Payments: A $25 fee is charged for returned automatic draft. Failure to pay the amount due under the contract results in default after 30 days. The Academy reserves its right to enforce payment as allowed by law.

Payment Information

Date of First Payment *

Monthly Amount *

Enrollment Fee

T-Shirt Size (if applicable)

Preferred Payment Day *

Payment Arrangement Notice: Payment arrangements, including ACH/check authorization if applicable, will be completed separately with the academy. This online form does not collect bank account information or check images.

I have read and agree to the terms of this membership agreement. *

I understand payment arrangements will be completed separately with the academy. *

Signature

Authorized Signature (Student or Parent/Guardian) *
Type full name to sign electronically

Signature Date *

Sandro Sampaio Brazilian Jiu-Jitsu Academy LLCCarlson Gracie TeamMembership Agreement