INTRODUCTORY INFORMATION
PARENT/LEGAL GUARDIAN'S NAME:
STUDENT'S NAME/S:
ADDRESS:
HOME PHONE:
DATE OF BIRTH/S: AGE/S:
EMAIL:
RESIDED IN AREA: YRS MOS
PLAN TO BE IN AREA: YRS MOS
EMERGENCY CONTACT:
EMERGENCY PHONE:
STUDENT QUESTIONNAIRE
1. Have you studied any type of Martial Arts before? Yes or No?
If yes, what style, where, and how long?
2. What motivated you to come see us today?
3. How long have you been thinking about taking Martial Arts classes?
Not too long A couple of months Over a year
4. If you have been thinking about taking Martial Arts classes for over a couple of months, what stopped you from starting before now?
5. Check the benefits you would like to gain from your Martial Arts training (check the 5 most important):
- Self-Defense
- Self-Confidence
- Self-Motivation
- Respect
- Coordination
- Weight Control
- Self-Control
- Balance
- Obedience
- Character
- Physical Fitness
- Self-Discipline
- Focus
- Muscle Tone
- Positive Attitude
- Academic Achievement
- Concentration
- Quickness
- Stress Management
- Leadership
- Flexibility
- Goal Setting
- Perseverance
- Alertness
6. What other team sports or activities do you participate in?
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Soccer
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Baseball
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Football
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Hockey
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Lacrosse
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Golf
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Track/Running
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Ballet
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Gymnastics
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Cheerleading
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Other
7. If accepted into our school, can you attend class at least 2 times a week? Yes No
8. If accepted into our school, can you apply 15 minutes per day practicing at home? Yes No
9. If accepted into our school, would you set a goal to become a Black Belt or just learn a few basics?
10. Our academic policy for a young Black Belt is a “B” average or better. If you are a below “B” average student, do you think you can bring your grades up to a “B” average before you attain the Black Belt? Yes No
Risk Evaluation
Please read the following statements carefully, and check those that are true
If I checked any one of the statements as true, I will receive a medical evaluation and consent before I may take a fitness test and participate in exercise class.
Signature of Student (Parent or Guardian, if student is a minor) Date
| WAIVER OF INJURY | INFORMATION DATE: |
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Guest Student represents that he or she is in good physical condition and able to use the equipment provided and to participate in exercises and martial arts programs made available by CMAA, LLC., hereinafter referred to as “The Studio.” The Studio represents that its personnel are trained in providing exercise programs and instruction and the proper use of its equipment. The Studio further represents that its personnel have no expertise in diagnosing, examining, or treating medical conditions of any kind or in determining the effect of any specific exercise on said medical condition. Guest Student fully understands and agrees that in participating in one or more of the martial arts programs, or using the facilities maintained by The Studio, there is the possibility of accidental or other injury. Guest Student agrees to assume the risk of such injury and further agrees to indemnify The Studio and its personnel from any and all liability on the part of The Studio by either the Guest Student or third party as the result of the use by the Guest Student of the facilities and instructions offered by The Studio. By signing below, you certify that you understand and comply with this waiver. I ALSO ACKNOWLEDGE THAT THERE ARE NO REFUNDS FOR THE INTRODUCTORY TRIAL. Signature (I certify that I am at least 18 years of age.) |
INFORMATION SOURCE: |
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| INTRO FEE: $59UNIFORM SIZE: | |
| INTRO COURSE: | |
| DATE ENROLLED: | |
| DATE INTRO EXPIRES: | |
| STAFF CHECKLIST:
Pre Intro Checklist: New schedule given? Payment Received? Post Intro Checklist: E-mail address entered? ID card made? Filed in appropriate folder? Enrollment Checklist: Extension conference on 2nd class?? |
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10% DISCOUNT FOR ACTIVE MILITARY, LAW ENFORCEMENT, FCPS PERSONNEL! |
Instructor's Evaluation: |
