Please provide student information: * = Required fields  

*First Name
*Last Name
*Age
Birthday

Please provide Parent/Guardian information if Student is under 18:

Adult's First Name
Adult's Last Name
*Street Address
Address (cont.)
*City
*State
*Zip

I am fully aware that Martial Arts America will provide quality instruction and supervision and that the center shall not be held responsible for any mishaps or accidents.

Have you already spoken to a representative, and have a reserved appointment date and time?

If so, please  enter that information below:

How can we contact you?

Work Phone
*Daytime Phone
*E-mail

How did you hear about us?

Advertisement	(Name)
Sign (Drive or Walk By)
Student Referral	(Name)
Yellow Pages
Other	(Name)

Registration Code

(Enter Code)

Does the student have any medical problems that the Instructor should be aware of?:

No
Yes
If yes, list:

Comments:

Submit Application:

Martial Arts America reserves all rights to dismiss any students, at any time for conduct or actions which may convey a bad image. I hereby acknowledge that Martial Arts America is not responsible for any injuries suffered while on these premises.

Check one applicable box: