CHILD PARTICIPANT FORM:
Todays Date
*
-
Month
-
Day
Year
Date
Parent Name:
*
First Name
Last Name
Address of Parent
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Email Address
*
example@example.com
Parent Phone Number
*
How did you hear about us?
*
Please Select
website
Facebook
Walked by the studio
Drove by the studio
Google Search
Bing Search
Yahoo Search
In Studio Event
Offsite Event
Referred by a current member
Referred by a former Student
Referred by an instructor
Referred by a school teacher
Studio Seminar
Child Name:
*
First Name
Last Name
Child Date of Birth
*
Child Age
*
Gender
Male
Female
Back
Next
Has your child ever trained in any martial arts or self-defense before?
*
Yes
NO
Is your child currently involved in any sports, activities, or exercise program?
*
Yes
NO
*
Yes
NO
N/A Doesn't apply to my child-Not involved in anything
Is your child planning on leaving the area for either a short time period or for an extended period of time within the next 12 months?
*
Yes
NO
Have you set aside a budget for your child's training?
*
Yes
NO
Can you comfortably budget somewhere between $40 to $80 each week for your child’s training?
*
Yes
NO
After the trial class, is there anyone you need to consult with before enrolling your child for classes?
*
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 get your child started?
*
Today
Tomorrow
This Week
Next Week
sometime this month
Next month
Does your child have any physical limitations or injuries?
*
Yes
NO
If yes, Please explain?
Does your child have any medical conditions?
*
Yes
NO
If yes, Please explain?
Is your child currently taking any kind of medication?
*
Yes
NO
If yes, Please explain?
Back
Next
What type of workout are you interested in for your child? Select one:
*
Light-Workout
Moderate-Workout
Hard-Workout
How many days a week would you like your child to attend classes? Select one:
*
One-Day a Week
Two-Days a Weeks
Three-Days a week
Four-Days a Week
Five-Days a Week
Selects all the days & times that's best for your child to attend classes?
9am
10pm
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What is your child 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 for your child? 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 your child 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
Submit
Should be Empty: