HEALTH DECLARATION

We prioritise your safety and well-being so that you have a fun and enjoyable experience. Our team takes Jiu Jitsu seriously and we are committed to providing you with the best training possible.

To help us understand your requirements better please complete our Health Declaration and Questionnaire.

Health Declaration & Questionnaire

Please fill out the following form. * denotes a required field

First name*

Last name*

Email*

Mobile*

Date of birth*

Day

Month

Year

I understand Jiu Jitsu and Self-Defence is a contact Martial Art and I am aware of the inherent risks and have read the AVBJJ Terms & Conditions, Liability Waiver and Privacy Policy.*

Yes

1. Have you been hospitalised in the last 12 months?*

Yes

2. Are you suffering from a medical condition, illness or injury?*

Yes

3. Do you have a heart condition?*

Yes

4. Do you experience unexplained pains in your chest during or after physical exercise?*

Yes

5. Have you experienced an asthma attack in the last 12 months?*

Yes

6. If you have diabetes (type 1 or 2) have you had trouble controlling your blood glucose in the last 3 months? *

Yes

7. Do you have any muscle, joint or bone issues that could be made worse participating in physical activity or exercise?*

Yes

8. Do you have any injuries that may limit you in participating in Jiu Jitsu?*

Yes

9. Do you need a Doctor's clearance to participate in Jiu Jitsu?*

Yes

10. Have you ever been physically assaulted, attacked and were unsure how to defend yourself?*

Yes

Yes, and I have some Self-Defence knowledge.

11. Are there any specific goals or defence techniques you wish to learn

If you answered 'Yes' to any health questions or question #10, please provide more details.

Signature (if under 18 years signed by parent or guardian)

I declare that the above is true and correct.

Your information will be kept confidential as per our Privacy Policy.

CONTACT ME

EMAIL OR CALL ME IF YOU HAVE MORE QUESTIONS

steve@AVBJJ.nz
021-675 939

Thanks for submitting!

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