Adult Guest Registration Form

Student Name: _________________________________________ D.O.B.: ____________________ M/F: _______

Spouse: _____________________________________ Occupation: _______________________________

Home #: _______________________ Cell #: ________________________ Email: _____________________________

Address: ________________________________________________________________________________________

City: ___________________________________________ Postal Code: _____________________________________

1. How did you happen to hear about us:
 Phone Book  Radio/TV  Mailer Coupon
 Newspaper  Demo  Referred by: _____________
 Sign  Birthday Party  Other: ____________

2. Do you live in the area?  Yes  No

Do you work in the area?  Yes  No
Do you plan on to remain in the area?  Yes  No

3. Are you in good health with no physical problems?  Yes  No

If no, please list any medical conditions we should be aware of: ___________________________________________

4. Do you have a place in which you can practice what you learn in class?  Yes  No

5. Is your schedule such that you can arrange to take lessons twice a week?  Yes  No

6. Is there anyone you would like to take lessons with?  Yes  No

Name: ________________________

7. Do you have any previous martial arts experience?  Yes  No

Please continue on to the other side

8. How long have you been interested in taking martial arts?
 Not to long  Couple of Months  Over 1 year

9. Do you feel your significant other would support your decision in getting in shape and learning self-defense?
 Yes  No

10. What has prevented you from getting started in a program in the past?
______________________________________________________________________________________________

11. Is this still a problem?

______________________________________________________________________________________________

You will receive all benefits listed below, but please check the most important benefits you would like to receive from
your training here at Kick City Martial Arts Fitness.

MENTAL BENEFITS
Spirit Character Self Control Concentration
Focus Motivation Self Esteem Determination
Listening Obedience Goal Setting Goal Setting
Alertness Leadership Self Respect Manage Stress
Discipline Persistence Better Grades Self Confidence

PHYSICAL BENEFITS
Mobility Relaxation Conditioning Fitness
Exercise Endurance Reflexes Fun
Flexibility Muscle Tone Weight Control Self Defense
Agility Speed Coordination Strength
Power Balance Cardiovascular Control

In consideration for my attendance and participation in the martial arts training offered by Kick City Martial Arts Fitness,
I acknowledge the existence of certain inherent risks n this type of training and hereby agree to assume all risks. I
further relieve the school, its management, assigned staff, and fellow students from liability resulting from loss, whether
personal belongings or bodily injury. I also hereby state that I am physically fit to take the prescribed course of
instruction and do so of my own free will in exchange for an agreed upon fee. I understand there is no refund policy on
any monies I will pay to Kick City Martial Arts Fitness.

Signed: ______________________________________________ Date:_______________________________