Empower Martial Arts Academy
8776 Lantana Rd. Suite A-112 Lake Worth, Florida 33467 561-336-5554 / Empowermaa@gmail.com / Empowermaa.com
Welcome to Empower Martial Arts Academy!
Thank you for starting your journey with Empower Martial Arts Academy — where confidence, discipline, and respect are at the heart of everything we do.Whether you're joining us for camp, our after school program, or Taekwondo/Kickboxing classes, we're excited to support your growth every step of the way.
Account Email Address
*
This will be the main email we use for your registration, including all communications, file access, and program updates. Please use a personal email you check regularly. If enrolling multiple students, this email will apply to the entire household account.
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Student Information
Please fill in the basic information about the student/s who will be enrolling in the program.
Enrollment Date
*
/
Month
/
Day
Year
Date
Student's Full Name
*
First Name
Middle Name
Last Name
Suffix
Student's Phone Number
THIS IS OPTIONAL. Skip if the student does not have a phone number.
Format: (000) 000-0000.
Today's Date
/
Month
/
Day
Year
Date
Student's Date of Birth
*
/
Month
/
Day
Year
Date
Student's Age
*
This will be automatically populated after entering your birthdate. Feel free to correct it if the calculation was a mistake.
Is the student currently enrolled in or attending school?
*
Yes
No
School Name
*
School Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Grade Level
*
Preschool / Pre-K
Kindergarten (K)
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade (Freshman)
10th Grade (Sophomore)
11th Grade (Junior)
12th Grade (Senior)
Other
T-shirt Size
*
Please Select
Youth - XS
Youth - S
Youth - M
Youth - L
Adult - S
Adult - M
Adult - L
Adult - XL
Please note that t-shirt will may not be provided for Flip Squad enrollees.
Program Selection & Requirements
Please review and complete the questions below based on the program your child will be participating in. This helps us tailor their experience, ensure we meet any specific needs, and prepare for any program-specific guidelines or requirements. If you've selected more than one program, answer all questions that apply to your child’s enrollment.
Which program(s) would you like to enroll your child in?
*
Taekwondo/Kickboxing Enrollment
Camp Enrollment
Aftercare Program Enrollment
Flip Squad Enrollment
No School Camp
Thanksgiving Week Camp
Winter Break Camp
Spring Break Camp
Parents' Night Out
Would you like to enroll your child for the full 10-week summer camp, or only selected weeks?
*
Full Summer Camp (June 1-August 7)
Selected Weeks Only
Weeks attending camp?
*
Week 1 June 1 – June 5
Week 2 June 8 – June 12
Week 3 June 15 – June 19
Week 4 June 22 – June 26
Week 5 June 29 – July 3
Week 6 July 6 – July 10
Week 7 July 13 – July 17
Week 8 July 20 – July 24
Week 9 July 27 – July 31
Week 10 August 3 – August 7
Can the student swim?
*
Please Select
Yes
Yes, with some assistance
No
How would you rate the student’s swimming ability?
*
Beginner
Intermediate
Expert
Can the student roller skate?
*
Please Select
Yes
No
Can the student watch PG movies?
*
Please Select
Yes
No
Would you like to provide information for another child?
*
Please Select
Yes
No
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Student Information
Please fill in the basic information about the student/s who will be enrolling in the program.
Enrollment Date
*
/
Month
/
Day
Year
Date
Student's Full Name
*
First Name
Middle Name
Last Name
Suffix
Student's Phone Number
THIS IS OPTIONAL. Skip if the student does not have a phone number.
Format: (000) 000-0000.
Today's Date
/
Month
/
Day
Year
Date
Student's Date of Birth
*
/
Month
/
Day
Year
Date
Student's Age
*
This will be automatically populated after entering your birthdate. Feel free to correct it if the calculation was a mistake.
Is the student currently enrolled in or attending school?
*
Yes
No
School Name
*
School Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Grade Level
*
Preschool / Pre-K
Kindergarten (K)
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade (Freshman)
10th Grade (Sophomore)
11th Grade (Junior)
12th Grade (Senior)
Other
T-shirt Size
*
Please Select
Youth - XS
Youth - S
Youth - M
Youth - L
Adult - S
Adult - M
Adult - L
Adult - XL
Please note that t-shirt will may not be provided for Flip Squad enrollees.
Program Selection & Requirements
Please review and complete the questions below based on the program your child will be participating in. This helps us tailor their experience, ensure we meet any specific needs, and prepare for any program-specific guidelines or requirements. If you've selected more than one program, answer all questions that apply to your child’s enrollment.
Which program(s) would you like to enroll your child in?
*
Taekwondo/Kickboxing Enrollment
Camp Enrollment
Aftercare Program Enrollment
No School Camp
Thanksgiving Week Camp
Winter Break Camp
Spring Break Camp
Parents' Night Out
Would you like to enroll your child for the full 10-week summer camp, or only selected weeks?
*
Full Summer Camp (June 1 – August 7)
Selected Weeks Only
Weeks attending camp?
*
Week 1 June 1 – June 5
Week 2 June 8 – June 12
Week 3 June 15 – June 19
Week 4 June 22 – June 26
Week 5 June 29 – July 3
Week 6 July 6 – July 10
Week 7 July 13 – July 17
Week 8 July 20 – July 24
Week 9 July 27 – July 31
Week 10 August 3 – August 7
Can the student swim?
*
Please Select
Yes
Yes, with some assistance
No
How would you rate the student’s swimming ability?
*
Beginner
Intermediate
Expert
Can the student roller skate?
*
Please Select
Yes
No
Can the student watch PG movies?
*
Please Select
Yes
No
Would you like to provide information for another child?
*
Please Select
Yes
No
Back
Next
Student Information
Please fill in the basic information about the student/s who will be enrolling in the program.
Enrollment Date
*
/
Month
/
Day
Year
Date
Student's Full Name
*
First Name
Middle Name
Last Name
Suffix
Student's Phone Number
THIS IS OPTIONAL. Skip if the student does not have a phone number.
Format: (000) 000-0000.
Today's Date
/
Month
/
Day
Year
Date
Student's Date of Birth
*
/
Month
/
Day
Year
Date
Student's Age
*
This will be automatically populated after entering your birthdate. Feel free to correct it if the calculation was a mistake.
Is the student currently enrolled in or attending school?
*
Yes
No
School Name
*
School Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Grade Level
*
Preschool / Pre-K
Kindergarten (K)
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade (Freshman)
10th Grade (Sophomore)
11th Grade (Junior)
12th Grade (Senior)
Other
T-shirt Size
*
Please Select
Youth - XS
Youth - S
Youth - M
Youth - L
Adult - S
Adult - M
Adult - L
Adult - XL
Please note that t-shirt will may not be provided for Flip Squad enrollees.
Program Selection & Requirements
Please review and complete the questions below based on the program your child will be participating in. This helps us tailor their experience, ensure we meet any specific needs, and prepare for any program-specific guidelines or requirements. If you've selected more than one program, answer all questions that apply to your child’s enrollment.
Which program(s) would you like to enroll your child in?
*
Taekwondo/Kickboxing Enrollment
Camp Enrollment
Aftercare Program Enrollment
No School Camp
Thanksgiving Week Camp
Winter Break Camp
Spring Break Camp
Parents' Night Out
Would you like to enroll your child for the full 10-week summer camp, or only selected weeks?
*
Full Summer Camp (June 1 – August 7)
Selected Weeks Only
Weeks attending camp?
*
Week 1 June 1 – June 5
Week 2 June 8 – June 12
Week 3 June 15 – June 19
Week 4 June 22 – June 26
Week 5 June 29 – July 3
Week 6 July 6 – July 10
Week 7 July 13 – July 17
Week 8 July 20 – July 24
Week 9 July 27 – July 31
Week 10 August 3 – August 7
Can the student swim?
*
Please Select
Yes
Yes, with some assistance
No
How would you rate the student’s swimming ability?
*
Beginner
Intermediate
Expert
Can the student roller skate?
*
Please Select
Yes
No
Can the student watch PG movies?
*
Please Select
Yes
No
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Next
Parent/Guardian Information
Kindly provide the contact details of the student’s parent(s) or legal guardian(s). This allows us to reach out regarding attendance, emergencies, or updates.
Parent/Guardian 1: Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Do you want to submit another parent/guardian's information?
*
Yes
No
Parent/Guardian 2: Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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OPTIONAL: Authorized Pickup List
Please list individuals (other than the parents/guardians) authorized to pick up the student from our program. This section is optional — feel free to skip if no additional authorized individuals are needed at this time.
Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Medical Information & Emergency Authorization
Your children's safety is our priority. Please let us know of any relevant medical information and grant permission for emergency procedures, if necessary.
Do we have permission to consult with your family physician and/or send the students to the hospital emergency room in the event of a serious illness or accident?
*
Please Select
Yes
No
If yes, please provide your doctor's information
*
Doctor's Name / Hospital or Clinic / Phone Number
Do the students need any medication while in our program?
*
Please Select
Yes
No
If yes, please provide name/s of medication, dosage and frequency
*
Medicine - Dosage - Frequency
Do the students have any medical problems which we should be aware of?
*
Please Select
Yes
No
If yes, please specify below
*
Do the students have active health insurance coverage?
*
Please Select
Yes
No
If yes, please provide Insurance Provider / Company Name
*
Policy Number
*
Policy Expiration Date
*
/
Month
/
Day
Year
Date
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Program Agreement, Waiver, Code of Conduct and Payment
This section outlines important information about payment, safety, media consent, behavior expectations, and your acknowledgment of program policies.
Before proceeding, please take a moment to carefully read the following agreement. It includes important information about program safety, conduct expectations, emergency procedures, and media consent.
I acknowledge and agree to the following payment policies for Empower Martial Arts Academy.
*
Aftercare must be paid by the last day of the prior month.
Camp must be paid by the Friday of the week before the camp begins.
Special events must be paid at least one day prior to the event.
Failure to pay by the due dates will result in a $25 late fee per child, applied after a one-week grace period. An additional $25 late fee per week will be added for each week the payment remains unpaid.
If the balance becomes one month past due, all services-including school pickup—will be suspended until payment is made in full, and your account may be sent to collections.
By entering your full name and signature at the end of this section, you confirm your understanding and acceptance of these terms either as the student or on behalf of the enrolled student.
*
I understand that participation in martial arts, after school programs, and camps may involve physical activity and inherent risks. I voluntarily accept full responsibility for any potential injuries or incidents that may occur during participation. I agree to release Empower Martial Arts Academy, LLC, its staff, instructors, and affiliates from any liability related to injury, loss, or damage arising from participation in any program or event, including field trips and physical activities.
In the event of an emergency, I grant permission for the academy to seek medical attention from licensed professionals, including transportation to a hospital or medical facility, should it be deemed necessary.
I also grant permission for Empower Martial Arts Academy to photograph or record my child (or myself) during classes and events. These materials may be used for promotional, educational, or informational purposes across print, digital, or social media platforms. I waive the right to review or approve final versions and understand no compensation will be provided for such use.
I understand that the program enforces a clear Code of Conduct, including a three-strike system for rule violations and a zero-tolerance policy for bullying. Disruptive, disrespectful, or inappropriate behavior — including physical aggression, verbal abuse, profanity, or bullying of any kind — may result in disciplinary action, including removal from the program. I agree to support these values and will encourage my child to act with integrity, kindness, and respect both in and out of class.
I have read and understood the Program Agreement, Waiver, and Code of Conduct provided. By entering my full name, I acknowledge and agree to all terms stated, and understand that this serves as my digital agreement.
*
Participant’s full name (if over 18) or parent/guardian’s full name (if under 18)
Signature
*
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🎯 Student Goal & Growth Reflection (Optional but encouraged, please click NEXT to skip this part)
We encourage you to complete this section to help us better understand your child’s needs, motivations, and personal development goals. This is not mandatory, but it helps us support your enrollee/s more effectively throughout their journey with us!
What are your main goals for enrolling the student/s in our martial arts program?
Build self-confidence and self-esteem
Improve focus and discipline
Develop physical fitness and coordination
Learn effective self-defense skills
Instill values like respect and integrity
Support emotional regulation and self-control
Other
Rank the following areas based on what matters most (drag and drop the categories below to rank them in order of importance, from top to bottom).
What is one thing you hope your child will gain or improve in the first 3 months?
Is there anything you’d like us to know about your child’s learning style, personality, or needs?
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Spreading the Word
We’d love to know how you found out about us! Please select the option that best describes where you first heard about Empower.
How did you hear about Empower?
*
School
Event
Family or Relative
Friends
Word of Mouth
From a Current Employee
Other
Type the school/event here
*
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