The Factory

Assumption of Risk

Waiver of Liability

I, ____________________ {name} (client name), hereby agree that by signing this document, I consent to waive certain legal rights, including the right to sue the following party, and, if applicable, its owners, trainers, representatives, and facilities from any physical, material, tangible or intangible, loss or damages that may happen to me during my participation in any of the fitness services (hereinafter, "Fitness Services") undertaken while under their instruction or thereafter: The Factory (the "Fitness Provider").

I will be voluntarily participating in the Fitness Services that will be conducted by the Fitness Provider. These Fitness Services will include, but not be limited to the following:

Jiu jitsu, wrestling, grappling, weight training and fitness, yoga, toddler/youth fitness the following is the identifying and contact information for me, the client ("Client"):

Client Legal Name {name}: _________________________________

Parent Legal Name (if Client is under 18) {name}: ___________________________

Client Address {address}: _________________________________________________

Client Phone Number {phone}: ________-________-__________

Client Date of Birth {dob}: ______/______/_______

The following is the identifying and contact information of the Fitness Provider:

          Business Address:       220 S 2nd Street, Dillsburg Pa 17019

Business Contact Number:   717 525-2004

My initials below indicate that I agree with and understand the following:

________It is my responsibility to consult a physician before participating in this or any fitness program and I affirm that I have no medical conditions that would restrict me from participating in any of the Fitness Services.

________I agree to hold the Fitness Provider, and if applicable, its owners, trainers, and representatives, harmless from any damage, whether tangible or intangible, that may happen to me while participating in the Fitness Services. Such injuries or illness may include, but are not limited to, transmissible diseases including but not limited to COVID19, muscle strains, muscle sprains, muscle spasms, heart attacks, raised blood pressure, and broken, fractured, or dislocated bones.

________I agree that the Fitness Provider offers the Fitness Services with no guarantee of results. I agree that I am solely responsible to maintain the diet and fitness regime appropriate for my level of health and stamina, and I agree that any results that occur, whether positive or negative, are the effects of my own personal choices.

________ I agree that participation in the Fitness Services is not a replacement for actual medical care, and that if I do experience medical issues, I will contact my doctor immediately.

________I agree and verify that all the information that I have given the Fitness Provider and its representatives is accurate, up-to-date, and without the omission of any known medical issues.

________I agree and verify that If I have omitted any necessary personal information, whether knowingly or unknowingly, I will hold the Fitness Provider harmless against all liability for any damages that may occur to myself or to others because of my actions or inactions.

________I agree to keep the Fitness Provider apprised of any changes or upcoming changes concerning my physical health and personal information.

________I understand and agree that it is my responsibility to let the Fitness Provider know if I find myself in any pain or discomfort before, after, or during the Fitness Services.

________ If I do require medical treatment or attention while or after participating in the

Fitness Services, I agree that the medical costs are mine and mine alone and hold the Fitness Provider blameless from any charges, fees, or costs that my conditions may incur.

This Fitness Services Waiver will bind and be enforceable against me and all my personal representatives. I agree that this Fitness Services Waiver should be enforceable to the fullest extent of the law, and if any portion is held invalid, the remainder should continue in full legal force and effect.

I specifically acknowledge and agree that this document is not intended to be a general release, which would be limited under some state and local laws.

This Fitness Services Waiver shall be construed and interpreted as broadly as possible in the applicable jurisdiction.

ASSUMPTION OF RISK. I understand and am aware that my participation in the Fitness Services involves risks. These risks may lead to tangible or intangible harm, and I agree that they may result not only from my own actions but also from the actions of others. With the knowledge and understanding of these risks, I choose, of my own will and volition, to continue participating in the Fitness Services.

I am also aware that there are risks that I may not have considered, yet I waive my right to any claims that may occur from these unconsidered risks, and I choose, of my own will and volition, to participate in the Fitness Services.

COVENANT NOT TO SUE. I will not start any lawsuit or other court action against the Fitness Provider, nor will I join any such proceeding, including any claim for money damages. I acknowledge and agree that I am entering a covenant not to sue the Fitness Provider in any capacity, including to hold the Fitness Provider liable for any injury, loss, or damage sustained by me or my property, even if it is due to the Fitness Provider's negligence or omission. I also waive the right of any of my insurers' to make any such claim.

INDEMNIFICATION: I agree to defend and indemnify the Fitness Provider and any of its affiliates (if applicable) and hold them harmless against any and all legal claims and demands, including reasonable attorney's fees, which may arise from or relate to my use or misuse of the Fitness Services or my conduct or actions. I agree that the Fitness Provider shall be able to select its own legal counsel and may participate in its own defense, if desired.

REPRESENTATION: I am over 18 (eighteen) years of age and am medically and physically able to participate in the Fitness Services.

GOVERNING LAW: This Fitness Services Waiver shall be governed by and construed in accordance with the internal laws of Pennsylvania without giving effect to any choice or conflict of law provision or rule. Each party irrevocably submits to the exclusive jurisdiction and venue of the federal and state courts located in the following county in any legal suit, action, or proceeding arising out of or based upon this Fitness Services Waiver: ________

I have read the above Fitness Services Waiver fully and I understand and agree to its contents. I understand and agree that by signing this Fitness Services Waiver I forfeit any right, claim, or ability to hold the Fitness Provider responsible for any tangible or intangible damages, loss of property, or loss of life that may occur during or after my use of the facilities and participation in the Fitness Services.

__________________________________________________________

Client Name {name}

__________________________________________________________

Client Signature

___________________________________________________________

If Client is a minor, Parent/Guardian Name ____________________________________________________________

If Client is a minor, Parent/Guardian Signature

____________________________________________________________

Date {sign_date}

Primus Grappling at The Factory

 Registration and Contract

Full Name {name}: ______________________________________________________________

Age: _____ Date of Birth {dob}: ____/____/_____ 

To Be Completed by Student And / Or Parent / Guardian – If Under Age 21

Student and / or Guardian Name:

Full Name {name}: ______________________________________________________________

Cell Phone {phone}: _______________ Emergency Contact {contact_name}: ____________________ 

Emergency contact phone {contact_phone}: _______________________

Emergency contact relation {contact_relation}: _________________________________________

Address {address}: _____________________________ City:  ___________________

State and Zip:  ___________________   Email: __________________

Waiver and Release

I do hereby agree to participate in Primus Grappling, Primus Wrestling and Primus Brazilian Jiu Jitsu (referred to as “Company”) located at 220 S 2​^Nd​ St Suite F, Dillsburg Pa 17019. The responsible party must read the entire contract before signing. 

 I understand that I will be bound by the contract that I register for. Those contracts are for 1mo, 3mo, 6mo, and 12mo depending on which program I sign up for.  Students renewing will pay their monthly registration fee on or before the day of the month they signed their contract. Tuitions are due and must be paid on or before the contract date, regardless of Student’s absence, major holidays, and / or school holidays. I understand that I will receive two courtesy bill reminders, and that tuition not received by the contracted date(s) will assess a late charge, starting at $15.00. Declined cards and insufficient funds will result in a $25.00 penalty fee. Be advised that it is the student and / or Guardian’s responsibility to make sure payment is received on time. Delinquent accounts will be turned over to a collection agency. On-Line Bill Pay is the preferred method of receiving payment. 

I understand that students may not terminate their contract without prior approval and scheduling with the Company’s office. If you wish to terminate your membership, there is a Early Termination Fee of 50% of the remaining balance on the membership. In the case of injury or serious medical illness, the Company will handle on a case-by-case basis. Student or responsible party must bring in a doctor’s note stating the reason for the request and indicating as to when the student may return to class. If a student needs to change their schedule due to other sport obligations, or for any other reason, possible suspension of membership must be approved and confirmed by the Company’s office. A suspension period of 3 months is offered, during this time of suspension payments will continue, and the time of suspension used will be added onto the end of your membership period.  The signing below indicates that you have read the Waiver and Release guidelines, terms and conditions, and regulations on this contract and fully understand the contents. This contract will remain on file in The Factory office unless the terms and conditions change. At that time a new contract will be executed.

I have executed this Waiver and Release this {sign_date}___ day of ___, 20___.

___________________________________________________

Signature of Student or Parent / Guardian if under the age of 21 

___________________________________________________

Signature of Company representative 

ACH / Credit Card Payment Authorization  

❑ - ​Recurring Charge ​ – You authorize regularly scheduled charges to your Credit Card or Bank Account. You will be charged the amount indicated below each billing period. A receipt for each payment will be provided to you and the charge will appear on your Credit Card or Bank Account Statement. You agree that no prior notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected. 

I _______________________ authorize DBA The Factory Dillsburg to charge my Credit 

❑ - One (1) Time Charge​      – You authorize the merchant below to make a one-time charge to your Credit​    Card or Bank Account listed below. 

By signing this form, you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only and does not provide authorization for any additional unrelated debits or credits to your account. 

I _______________________ authorize DBA The Factory Dillsburg to charge my Credit 

Billing Details 

Billing Address{address} _________________________

Phone Number {phone} ___________________

City, State, Zip {address}   ______________________ Email __________________ 

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the merchant in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that the merchant may at its discretion attempt to process the charge again within 30 days and agree to an additional $25 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank; so long as the transactions correspond to the terms indicated in this authorization form. 

Individual's Signature ____________________________

Date{sign_date} ____________​