Martial Arts Gym Registration Form

• Monthly Membership Fee: $12
• Monthly Class Fee: $50
• Total Monthly Cost: $62

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medical have injuries?

Name *

First

Middle

Last

Date of Birth

Gender *

• Male
• Female
• Other

Unit of measurement *MetricImperial

Height (Cm) *

Weight (Kg) *

Feet *

Inches *

Weight (lbs) *

Phone *

Email *

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

Next

Do you have any medical conditions or injuries? *

• Yes
• No

Please explain *

Do you have health insurance? *

• Yes
• No

Are you currently on any medications? *

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Preferred Membership Plan *

Class Preference *

• Partoa Technique
• Parthowa Championship Match
• Coaching
• Wrestling
• Grappling
• Street Fight
• Self Defense
• Tournament referee
• Full Contact

Experience Level *

• Beginner
• Intermediate
• Advanced

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Confirmation

• I agree to the liability waiver and gym rules.
• I consent to receive communication via email or SMS.

Captcha *

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