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  Kids Program

  Intake Form

  Welcome to Phoenix Down Jiu Jitsu! Please complete the intake form below before participating in your first class. We appreciate you checking us out and are excited to have you on the mat with us!

  Form must be completed by a parent or legal guardian prior to their first class

   

  Contact Info

  
• Email Address
  

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  Make Required
• Mobile Phone
  

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  Make Required
• Participant First Name

  Participant Last Name
  

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  Make Required
• Participant Birthday (mm/dd/yyyy)
  

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  Make Required
• 2nd Participant First Name

  2nd Participant Last Name
  2nd Participant Birthday
  Add Another Participant
  
• Street Address
  Address Continued
  City

  State/Province
  Postal Code
  

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  Make Required
• Mom/Guardian First Name

  Mom/Guardian Last Name
  

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  Make Required
• Dad/Guardian First Name

  Dad/Guardian Last Name
  

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  Make Required
• What specifically would you like your child to accomplish in our a martial arts program?
  

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  Make Required
• What have you tried in the past to accomplish this?
  

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  Make Required
• Please check the benefits most important to you.

  Confidence

  Self Defense

  Self Esteem

  Respect

  Improved Behavior

  Physical Fitness

  Weight Control

  Strength & Flexibility

  Coordination

  Focus

  Competitive Sport

  Self Discipline

  Concentration

  Self Control

  Burn Energy

  Leadership

  Fun!

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  Make Required
  
  Confidence,Self Defense,Self Esteem,Respect,Improved Behavior,Physical Fitness,Weight Control,Strength & Flexibility,Coordination,Focus,Competitive Sport,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

  

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  Statements	Columns
  + Add New Statement	+ Add New Column

• Medical/Physical Limitations

  *You are not required to disclose any medical conditions. Only list conditions you want or think we should be aware of that could impact your child's training.

  
• Does your child have any medical concerns you want us to be aware of?
  

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  Make Required
• How did you FIRST hear about us?

  Referred By Friend Or Relative
  

  Facebook
  

  Instagram
  

  Google
  

  Passing By
  

  Other
  

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  Make Required
  
• Who referred you to us? (If applicable)

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  Make Required
  

• Social Media Consent

  We are thrilled to share our Jiu Jitsu school's journey and achievements on social media! As part of our community, you might find you or your child in group photos or videos of classes, events, and milestones. In addition to group settings, we love to celebrate and highlight individual accomplishments, shout outs, and special moments involving our members.

  
• Are you ok with us using images or videos that include you/your child, and sharing achievements or shout outs on our social media platforms?

  Yes I consent to having my/my child's images or achievements shared on social media.No I prefer not to have my/my child's image or achievements shared on social media.
  

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  Make Required
  

• I Agree

  I, the undersigned hereby waive all claims against any and all persons associated with Cedar Rapids BJJ LLC (DBA Phoenix Down Brazilian Jiu Jitsu). I understand that I am participating in a martial art which has body contact. I understand that this form of martial arts involves choke holds, arm locks, neck cranks, ankle locks, throws, slams, punches, kicks, elbows, knees, and such which could potentially cause serious injury or even death. I assume full responsibility for all my actions during and connected to the above organization. I understand the risk of participating in this form of martial arts training and hereby release Phoenix Down Brazilian Jiu Jitsu and all of its agents, employees, students, and associates of and from any and all liability, claims, demands, actions, medical bills, and causes of action whatsoever arising out of or relating to any negligent or other act or omission, and/or any loss, damage, or injury, including death, that may be sustained by the undersigned or any property of the undersigned in participating in this form of training. I, the undersigned also state that I am in good physical condition and know of no reason why I can not train in this form of training. I understand that in case of emergency, I hereby authorize any licensed medical personnel to perform any accepted medical assistance deemed necessary and I agree to bear the expense of any such treatment. As additional consideration for training at Phoenix Down Brazilian Jiu Jitsu, I agree that my attendance and/or performance at the academy and abroad at events and such may be photographed, filmed and/or taped and used by Phoenix Down Brazilian Jiu Jitsu for marketing purposes and I authorize the use of my image and I waive any compensation thereof – even if I discontinue my training at Phoenix Down Brazilian Jiu Jitsu. I acknowledge that I would like to receive correspondence from the academy via telephone, mail, and email. I, the undersigned, being duly aware of the risks and hazards inherent upon participating in this form of martial arts agree to all its rules, terms, and conditions. I acknowledge that I have received a copy of Phoenix Down Brazilian Jiu Jitsu rules and sparring rules, have read them, understand them, and agree to honor and obey them. I understand that disobeying the rules may, at the instructor’s discretion, result in suspension or expulsion from Phoenix Down Brazilian Jiu Jitsu and that I will not be entitled to a refund. In signing the foregoing release, the undersigned hereby acknowledges and represents: that he/she has read the foregoing release, understands it and signs it voluntarily; that he/she is over 18 years of age and of sound mind. If individuals participating are under 18, parent/legal guardian in signing this release agrees to all its terms and conditions.

  

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