ADULT PARTICIPANT FORM :
Todays Date
*
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Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Date of Birth
*
Age
*
How did you hear about us?
*
Please Select
Website
Facebook
Google Search
Bing Search
Yahoo Search
Drove by the studio
Walked by the studio
By an event held at the studio
Friend
Family Member
Referred by a current Member
Referred by a former Member
Studio Seminar
Flyer
by an offsite event
by an Instructor
Gender
Male
Female
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What classes are you interested in? Please Select one
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Defensive Only Self-Defense Class
Traditional Martial Arts Class
Combative Self Defense Class
Mixed Martial Arts Class
Have you ever trained in any martial arts or self-defense before?
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Yes
NO
Are you currently involved in any sports, activities, or exercise program?
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Yes
NO
If yes, will your participation in that activity, sport, or exercise program interfere with your ability to attend classes on a regular schedule?
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Yes
NO
N/A Doesn't apply to me-I'm not involved in anything
Is there a possibility that your work schedule could interfere with your ability to attend classes on a regular schedule during the next 12 months?
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Yes
NO
Are you planning on participating in anything in the future that could possibly prevent you from attending class during the next 12 months?
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Yes
NO
Are you planning on leaving the area for either a short time period or for an extended period of time within the next 12 months?
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Yes
NO
Do you plan on permanently moving during the next 12 months?
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Yes
NO
Have you set aside a budget for your training?
*
Yes
NO
Can you comfortably budget somewhere between $40 to $80 each week for your training?
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Yes
NO
After the trial class, is there anyone you need to consult with before signing up?
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Yes
NO
If yes or no, select one:
*
Spouse
Family Member
Partner
Friend
I don't need to consult with anyone
How soon where you looking to start?
*
Today After the trial class
Sometime This week
Sometime Nextweek
Sometime this Month
Next Month
Do you have any physical limitations or injuries?
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Yes
NO
If yes, Please explain?
Do you have any medical conditions?
*
Yes
NO
If yes, Please explain?
Are you currently taking any kind of medication?
*
Yes
NO
If yes, Please explain?
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What type of workout are you interested in? Select one:
*
Light-Workout
Moderate-Workout
Hard-Workout
How many days a week would you like to attend? Select one:
*
One-Day a Week
Two-Days a Weeks
Three-Days a week
Four-Days a Week
Five-Days a Week
Select all the days & times that's best for you to attend classes?
Rows
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What are you interested in learning? Select the ones that apply:
*
Martial Arts
Self-Defense
Ground fighting
Wrestling
Boxing
Weapons
Competition
Kickboxing
Flexibility
Strength and Conditioning
What are your training Objectives? Select the ones that apply:
*
Learn Self-defense
Fitness
Recreation
Meet new friends
Profession
Become an instructor
Competition
To earn a Black Belt
Which benefits you would like to receive from Martial Arts instruction? Select the ones that apply:
*
Self-Control
Self-Discipline
Improved listening Skills
Self-Confidence
Respect
Self-Esteem
Attitude
Concentration
Self-Defense
Physical Fitness
Weight Loss
Improved Flexibility
Stress Reduction
Improved Balance & Coordination
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