Membership Registration Form Online Registration New First Name * Last Name * Date of Birth * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email Address * Phone Number * Phone Number Type Mobile Work Home Registration Type * Choose a Registration TypeAdult 45-Day Temporary Membership $20Adult 6 Months $35Adult 1 Year $60Adult 2 Years $115Adult 3 Years $170Adult 4 Years $220Adult 5 Years $265 Youth 45-Day Temporary Membership $10Youth 6 Months $20Youth 1 Year $30Youth 2 Years $60Youth 3 Years $90Youth 4 Years $120Youth 5 Years $150 Senior 1 Year $15Senior 6 Months $10Senior 2 Years $30Senior 3 Years $45Senior 4 Years $60Senior 5 Years $75 Active Military no charge Youth (age 15 or younger) Adult (age 16 - 64) Senior (age 65 +) Sensei Name * Dojo * Choose Appropriate Rank * Jukyu (junior rank)Kukyu (junior rank)Hacjikyu (junior rank)Shichikyu (junior rank)Rokyu (white)Gokyu (blue)Yonkyu (green)Sankyu (brown 3)Nikyu (brown 2)Ikkyu (brown 1)-----------------------------ShodanNidanSandanYodanGodanRokudanShichidanHachidanKudanJudan I recommend this student for AJJF Registration Clear Sensei signs here Date of Application * This is a Waiver and Release of Liability: Clear REGISTRANT OR PARENT/GUARDIAN SIGNATURE HERE Registrant OR Parent/Guardian, please sign this Waiver and Release of Liability Agreement: “In consideration of this registration, I agree for myself, my heirs, successors and assigns to waive and release all liability, not file any lawsuit or any other action, and to indemnify and hold harmless the American Judo & Jujitsu Federation (AJJF), its directors, professors, officers, employees, committee members, instructors, members, registrants, affiliated dojos or schools for any injury, or other legal cause of action arising out of the study or practice of Danzan Ryu Jujitsu or any activity taught, practiced or conducted in connection with my registration in the AJJF. This waiver, release and indemnity includes, but is not limited to injuries or any other legal cause of action occur ring in classes, demonstrations, competitions or otherwise, and I waive and release any and all claims or rights that I may have in any jurisdiction for any liability arising out of any legal cause of action, including but not limited to, any liability from negligence and agree to indemnify and hold harmless the parties listed in the prior sentence. I understand that the study and practice of martial arts in general, and Jujitsu in particular is an inherently dangerous activity and may lead to serious and permanent physical injury and/or death. Intending to be legally bound by my signature below, I acknowledge the above and for all time knowingly and voluntarily assume any and all risks associated with the study and practice of Danzan Ryu Jujitsu or any mart ial art. The AJJF BOP reserves the right to suspend any individual or school registration at any time. I have read this waiver. I agree to adhere to the rules and standards of the AJJF. I further understand that only AJJF -sanctioned classes and events are covered by the AJJF group Insurance.” Notice The AJJF is a non- profit public benefit corporation and all donations, but not registration fees, are tax -deductible. If you are able to contribute more than your registration fee to support the programs of the AJJF, please indicate the donation amount below. All donations will be used to support instructional programs, scholarships, and propagation of the Danzan Ryu system. Your support of the AJJF is appreciated! Tax Deductible Donation Total * Captcha If you are human, leave this field blank.
