Apply for a Program

Participant Intake & Registration Form

First Name

Last Name

Student date of birth

What grade is the student in?

School Name

Home Address

City

State

Zip Code

Parent / Guardian #1 Information

Parent / Guardian #2 Information (if applicable)

Relationship to Student #1

Relationshion to Student #2 (optional)

Parent / Guardian #1 Phone

Parent / Guardian #2 Phone (optional)

Parent / Guardian #1 Email

Parent / Guardian #2 Email (optional)

Emergency Contact (If Different from Parent)

Emergency Contact Phone

Emergency Contact Email

Why are you interested in enrolling your child in this program?

Does your child have any of the following? (Check all that apply)

If yes, please list:

Is your child currently taking any medication?

If yes, please explain:

Are there any behavioral, emotional, or social challenges we should be aware of to better support your child?

Do you qualify for any of the following?

Household Income Range:

By enrolling, I understand:

My child is expected to attend at least 75% of scheduled classes This program requires consistent participation I will communicate absences in advance when possible

Parent's Signature

Date Signed by Parent

Student's Signature

Date Signed by Student

I acknowledge that martial arts training involves physical activity and inherent risk. I release the program, instructors, volunteers, and facility from liability for injuries sustained during participation, except in cases of gross negligence.

Parent's Signature

Date Signed by Parent

Code of Conduct Agreement

I understand that this program emphasizes:

Respect for instructors and peers
Discipline and self-control
Safety at all times
Positive sportsmanship

Failure to follow safety or conduct expectations may result in probation or dismissal.