RGDA - Royler Gracie David Adiv Association
RGDA Headquarters/ GNJA
56 Payne Rd, Lebanon, NJ08833, United States
ph: (908)713-0004
RGDA Association
Request for Affiliation - Application Form
Please type or print clearly
1 - Applicant Business/School name:
______
2 - Business owner/manager’s name: ______
Phone Number: ______
E-mail: ______
3 - BJJ Head Instructor’s name (if different than business owner) ______
Phone Number: ______
E-mail: ______
4 - Location information:
Address: ______
City: ______County/Area: ______
State/Province:______Country: ______
Website: ______
E-mail address: ______
Phone Numbers (please include area/international codes)
______
5 - Business/school information:
How long have you been in business?
______
What programs/disciplines/martial arts do you teach or are available in your school?
______
______
Please check all that apply to your facility:
( ) Grappling Mats Area
( ) Cardio/Fitness Area
( ) Weight Training Area
( ) Ring
( ) Cage
( ) Punching Bags
( ) Male Locker room
( ) Female Locker room
( ) Others – Please describe: ______
______
6 - Instructor’s Background:
How long have you been training Brazilian Jiu Jitsu?
______
Please list your ranksin BJJ, includingstripes (degrees) in each rank, date of promotion and who has promoted you:
RankDate of PromotionPromoted by
White Belt ______
Blue Belt ______
Purple Belt ______
Brown Belt ______
Black Belt ______
What type of services/programs would you like to offer to your community with the help of the RGDA Association?
____ Self Defense____ Gracie Jiu-Jitsu Gi ____ NO GI/Submission Grappling
____ NHB – No Holds Barred ____ Adult Classes ____ Women’s Classes
____ Kids Classes____ Teen Classes ____Competition Team
____ Classes for special populations (physical/mental disabilities)
____ Other: ______
Are you currently affiliated with any other BJJassociation or organization? Or have you been affiliated with another BJJ association before. Please note below:
______
______
Who has referred you to the RGDA Jiu Jitsu Association or how did you hear about us?
______
Please use the lines below for any additional information you would like to share with us at the present time:
______
______
______
______, declare that all the information and statements presented on this application form are true.
______
Applicant – Business owner signature Place and Date
______
Applicant – Head Instructor signature Place and Date
(if different than business owner)
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