Trial Class Student Evaluation Form

What day would you like to do your trial class? Choose from below: *

5:20 - 6:00 (Monday) 5:20 - 6:00 (Wednesday) 5:30 - 6:10 (Tuesday) 5:30 - 6:10 (Thursday) 6:40 - 7:20 (Tuesday) Ages 12 & Up 6:40 - 7:20 (Thursday Ages 12 & Up

Student's Name: *

First Name Last Name

Gender: *

Male Female Date of Birth: ____/_____/_____

Student's Name:

First Name Last Name

Gender:

Male Female Date of Birth: _____/_____/_____

Student's Name:

First Name Last Name

Gender:

Male Female Date of Birth: _____/_____/_____

Parent/Guardian Information 1

Name: *

First Name Last Name

Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home Number:

Area Code Phone Number

Cell Number: *

Area Code Phone Number

E-mail: *

Are you a student at another Martial Arts school? *

Yes No

If yes, Name of school:

Any physical or mental health conditions that may affect you (or your child's) ability to participate in class? *

Yes No

If yes, please explain:

What are you interested in? *

Evening Martial Arts Class After Care Program

Any Martial Arts Experience? *

Yes No

If yes, what belt level is your child?

What do you (your child) look to gain from learning martial arts?

Why are you (your child) interested in martial arts?

How did you hear about us? *

Drive by Website Facebook Saw our van

Referred by:

Waiver:

Martial arts is a contact sport. Members and guests use the school and equipment at their own risk. Kang's Mixed Martial Arts and staff are not responsible or liable for any damages from personal injuries, medical expenses or treatment, bodily injury, death, individual property, or any other loss, including but not limited to claims of negligence. Masters & instructors of Kang's MMA have been trained to teach Tae kwon Do, sparring, grappling and more. Masters and instructors will only teach with what they they were trained.

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Signature:

Date

Month Day Year

Trial Class Student Waiver Form