• Child's First Name

  Last Name
  

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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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• Email Address

  

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• Mobile Phone
  

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• Birthday
  

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• 2nd Participant First Name

  2nd Participant Last Name
  2nd Participant Birthday
  Add Another Participant
  
• 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 our a martial arts program?
  

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

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• Type of Student:

  Honor RollAbove AverageAverageNeeds a little help
  

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• Please check the benefits most important to you.

  Self-Confidence

  Self Esteem

  Respect

  Improved Behavior

  Physical Fitness

  Weight Control

  Strength & Flexibility

  Coordination

  Focus

  Self-Discipline

  Concentration

  Self-Control

  Burn Energy

  Leadership

  Fun!

  Bully Proof

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  Self-Confidence,Self Esteem,Respect,Improved Behavior,Physical Fitness,Weight Control,Strength & Flexibility,Coordination,Focus,Self-Discipline,Concentration,Self-Control,Burn Energy,Leadership,Fun!,Bully Proof

• 	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
  My Child Is Bully Proof	1	2	3	4	5

  

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  Statements	Columns
  + Add New Statement	+ Add New Column

• I agree

  In consideration for my child's attendance and participation in the martial arts training offered by Core Academy BJJ. I, the student/parent, 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 myself or my child is 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 Core Academy BJJ

  

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