Kids Quiz

Child's First Name

Last Name

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2nd Participant First Name

2nd Participant Last Name

2nd Participant Birthday

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Email Address
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Mobile Phone

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Birthday

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Mom's First Name

Mom's Last Name

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Dad's First Name

Dad's Last Name

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What specifically would you like your child to accomplish in a martial arts / Krav maga or fitness program ?

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Type of Student:

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Map this to an SPARK field:

Selection Box Items (seperated by commas)
Option 1,Option 2,Option 3
Please check the benefits most important to you.
Self-Confidence
Self Defense Skills
Self Esteem
Respect
Improved Behavior
Physical Fitness
Weight Control
Strength & Flexibility
Coordination
Focus
Self-Discipline
Concentration
Self-Control
Burn Energy
Leadership
Fun!

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Map this to an SPARK field:

Checkbox Items (seperated by commas)
Item1,Item2,Item3
Self-Confidence,Self Defense Skills,Self Esteem,Respect,Improved Behavior,Physical Fitness,Weight Control,Strength & Flexibility,Coordination,Focus,Self-Discipline,Concentration,Self-Control,Burn Energy,Leadership,Fun!

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
My Child Is Well Behaved At Home	1	2	3	4	5
My Child Is Well Behaved At School	1	2	3	4	5
My Child Is Confident In School	1	2	3	4	5
My Child Is Confident At Home	1	2	3	4	5
My Child is Athletic	1	2	3	4	5
My Child Is A Leader	1	2	3	4	5

Statements	Columns
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Why are you looking to start your child in a Martial Art, Self Defense or Fitness Program?

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Thanks For Taking The Time To See If You And Your Child Are A Good Match With Our Kids Programs At RMSDF.com