• First Name

  Last Name

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• Email Address

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• Mobile Phone

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• Street Address
  Address Continued
  City

  State/Province
  Postal Code

  Country United StatesUnited KingdomGermanyAustraliaCanadaFranceGrenadaArgentinaAustriaAzerbaijanBahrainBermudaBoliviaBrazilBrunei DarussalamChileColombiaCosta RicaCyprusDenmarkEcuadorFinlandGreeceHong KongIcelandIrelandIsraelItalyJamaicaJapanKorea, Republic ofKuwaitLuxembourgMexicoNepalNetherlandsNetherlands AntillesNew ZealandNorwayPanamaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarSerbiaSingaporeSouth AfricaSpainSwedenSwitzerlandThailandTrinidad and TobagoTurkeyUnited Arab EmiratesUruguayCzechia
  

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• Birthday
  

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• 2nd Participant First Name

  2nd Participant Last Name
  2nd Participant Birthday
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• What specifically would you like to accomplish in our a martial arts program?
  

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• Does you have any medical concerns that we should be aware of?
  

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• Level of physical fitness:

  ExcellentGoodFairPoor
  

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• Please check the benefits most important to you.

  Better Health

  Physical Fitness

  Stress Relief

  Relaxation

  Weight Loss

  Mind

  Body Spirit

  Appearance

  Weight Control

  Muscle Tone

  Mental Focus

  Fun Activity

  Confidence

  Endurance

  Flexibility

  Mental Focus

  Strength

  Inner Peace

  Self Protection

  Leadership

  Social Activity

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  Better Health,Physical Fitness,Stress Relief,Relaxation,Weight Loss,Mind, Body Spirit,Appearance,Weight Control,Muscle Tone,Mental Focus,Fun Activity,Confidence,Endurance,Flexibility,Mental Focus,Strength,Inner Peace,Self Protection,Leadership,Social Activity

• 	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
  I Am in Great Health	1	2	3	4	5
  I am Physically Flexible	1	2	3	4	5
  I Live a Stress Free Life	1	2	3	4	5
  I Am Confident In My Ability To Protect Myself/Family	1	2	3	4	5
  I Am Energetic	1	2	3	4	5
  I Am Physically Fit	1	2	3	4	5

  

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  Statements	Columns
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• I agree

  In consideration for my attendance and participation in the martial arts training offered by Jackson Brazilian Jiu-Jitsu Academy . I acknowledge the existence of certain inherent risks in this type of training and hereby agree to assume all risks. I further relieve the school, it's management, assigned staff and fellow students from any 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 a no refund policy on any monies I will pay Jackson Brazilian Jiu-Jitsu Academy

  

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