waiver form

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WAIVER - KEMANG BRAZILIAN JIU JITSU.

January 20, 2026 12:52 pm

BRING THIS COMPLETED FORM TO YOUR FIRST CLASS** **PLEASE DO NOT ENTER THE MATTED AREA WITHOUT HANDING IN THE FORM

I, (Name Of Participant) entirely upon my own initiative and risk and responsibility am about to participate in Brazilian Jiu-Jitsu training at Kemang Brazilian Jiu Jitsu with Fariz Luthfan. I am at least 18 years of age. If I am under 18 years of age, a parent or guardian will sign below on my behalf.  I understand that Brazilian Jiu-Jitsu can cause serious injury or even death. I will be learning to immobilize an opponent by choking them unconscious or causing major trauma to joints such as the shoulder, knee, or elbow. At some point everyone who trains in Brazilian Jiu-Jitsu long enough will suffer at least a minor injury. Knowing all of the above, I freely choose to participate in class and acknowledge my risk.  Therefore, I do hereby for myself, my heirs, executors, and administrators release and hold harmless Kemang Brazilian Jiu Jitsu and its board members, the head instructor Fariz Luthfan, Assistant Instructors and any guest instructors from any and all liability, negligence, claims, demands, actions or causes of actions, or caused of actions resulting from any participation in this sport/activity/class and associated activity.

Date

Student's Name

Guardian's Name (if under 18):

Phone Number

Signature (guardian if child under 18)

WAIVER FORM

WAIVER - KEMANG BRAZILIAN JIU JITSU.

January 20, 2026 12:52 pm

Jalan Emesde B No.11, RT.1/RW.6,
Cipete Sel. Kec. Cilandak.
Jakarta Selatan

De Entrance Arkadia, Rooftop (R) level, Jl. TB Simatupang No.kav 88, Kebagusan, Ps. Minggu, Kota Jakarta Selatan, 12520.

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