Dont Shoot Gym - Membership Registration

1
Student Full Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Day
Month
Year
3
Hapu (optional)
4
Email* This field is required.
example@example.com
5
Gender* This field is required.
Please Select
Please Select
Male
Female
Prefer not to say
Other
6
Parent / Guardian Full Name* This field is required.
First Name
Last Name
7
Parent / Guardian Phone Number* This field is required.
Area Code
Phone Number
8
Parent / Guardian Email* This field is required.
example@example.com
9
Emergency Contact Name* This field is required.
First Name
Last Name
10
Emergency Contact Phone Number* This field is required.
Phone Number
11
Relationship to Student* This field is required.
Please Select
Please Select
Parent/Guardian
Sibling
Relative
Friend
Other
12
Does the student have any injuries, medical conditions, or physical limitations we should know about?* This field is required.
No
Yes
13
Please provide details about the student's medical conditions, injuries, or physical limitations.* This field is required.
14
I understand martial arts involves physical activity and accept the inherent risks. I agree to follow gym rules and coach instruction at all times.* This field is required.
I acknowledge and agree.
15
Choose Membership* This field is required.
Kids Term Membership
Teens Term Membership
Adult Membership
16
Miscellaneous(any other notes)
Huge
Large
Normal
Small
Ok
Ok
17
SignaturePlease leave your signature below.
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