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Tiny Tigers Taekwondo (5 – 7 years old)
Juniors Taekwondo (7 – 12 years old)

Teen / Adult Taekwondo (13 + years)

Junior Jiu Jitsu / Bullyproof (7 – 12 years old)
Teen / Adult Gracie Combatives (13+ years)

Student Information

Name:	First: M.I. Last:
Birthdate:	/ / (Year) Age:
Address:
City:	State: Zip Code:
Home Phone:	- -
Work Phone:	- -
Cell Phone:	- -
E-mail:
Workplace or School:	Grade:
Education Level:	Honor Student Average Needs a little help
Other Activities:
Medical Concerns
Has your child ever been diagnosed with ADHD, Autism or a similar disorder? Yes No
Previous Martial Arts experience? Yes No
If Yes:	Current rank: Organization or ATA Number:

How did you hear about us?

What specifically would you like to accomplish (see your child accomplish) in our martial arts program?
1

2

3

(Please number in order of importance from 1 to 4)

1	2	3	4
				Self-Confidence (Self-Esteem, Assertiveness, Pride)
				Physical Fitness (Weight Control, Strength & Flexibility, Coordination)
				Self-Discipline (Concentration, Self-Control, Integrity)
				Self-Defense (Safety, Confidence, Awareness)