Roots Dojo: Student Application Form
Student Name
*
First Name
Middle Name
Last Name
Student Email
*
example@example.com
Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have you trained at Roots Dojo before?
*
No, I'm new here.
Yes, I'm a current/past student.
Birth Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Please Select
Male
Female
Non-binary
Prefer not to say
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which training program(s) are you interested in taking?
*
Why do you want to train at Roots Dojo?
*
Please tell us about your previous Martial Arts or related background:
*
How would you rate your current fitness level?
*
Please Select
Beginner (Just starting out)
Intermediate (Consistent but moderate)
Advanced (High intensity/Frequent training)
Elite/Professional (Competitive level)
Are there any pre-existing injuries or medical conditions we should be aware of?
*
Yes
No
Please explain:
*
I understand that it is my responsibility to monitor my own physical limits and inform the instructor if I feel any pain or discomfort during class.
*
I agree
What is your primary focus or goals?
*
How are you feeling physically since we last saw you?
*
Please Select
Better than ever!
Ready to jump right back in!
A bit rusty, need to pace myself.
Recovering from an injury.
Where did you hear about Roots Dojo?
*
Please Select
Word of Mouth
Social Media
Web Search
Former Student Returning
Additional Comments / Questions
Submit
Should be Empty: