Free Introductory Class Form In order to have a Free Intro Class you MUST book a class previously by filling up the form below. Data Protection: Your information will ONLY be used by Jorge Santos to inform about BJJ classes Appointment on: Wednesday, 28/06/2017 11:45Saturday, 24/06/2017 10:00Sunday, 25/06/2017 11:00 Full Name * Full Address * Postcode * Phone Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014 Email * Emergency Contact Name * Emergency Contact Number * Please tick the relevant boxes to all questions below: Have you ever been diagnosed with any of the following? Heart Disease Blood Pressure Other cardiovascular conditions Diabetes Asthma Epilepsy Special need or medical conditions that may affect your participation in an exercise programme Are prone to any of the following? Headaches Fainting Dizziness Pain or limited movement in any joint Pregnant or had a pregnancy within the last 3 months Taking any medication which could affect your ability to participate in this class First time you participate in a Brazilian Jiu-Jitsu class Under 18 and your parents or guardian give consent for you to participate in this Brazilian Jiu-Jitsu class Terms and Conditions * I agree to participate in Brazilian Jiu Jitsu classes at my own risk and will do so at a level appropriate to my abilities. I also give permission for my image to be used in any media or photography deemed solely for purpose of promoting Jorge Santos BJJ. If I have answered YES to any of the health questions above, I have discussed these with Brazilian Jiu Jitsu instructor from Jorge Santos BJJ and confirm that I accept full responsibility for participating in the class.