Student Application

We appreciate your interest and thank you for your application 

When you submit this application, and if you have not yet spoken with a representative, you will be contacted to discuss the program, schedules, conditions and payments.

If you have any questions, or wish additional information please email us at email@maakarate.com.

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?

Yes

No

If so, please  enter that information below:

Reserved Appointment date:
Time:   

How can we contact you?

Work Phone
*Daytime Phone  
*E-mail  

What are the main reasons why you and/or your family want to take martial arts lessons?

Physical Fitness Self Defense  
Self Control   Coordination 
Self Esteem   Cardio Fitness
Improve Focus   Fun  
Self Confidence Become a Black Belt 
Improve Grades Courtesy/Respect
Weight Loss An ''I Can'' Attitude
Friend or Family   Improved Self Image  

Did you realize that our Martial Arts Program can do those listed and more??

How did you hear about us?

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

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:

Applicant/student is over 18 years old 

Student is under 18 years old. I certify that I am the parent or legal guardian of the name applicant/student


Copyright © 2003 Martial Arts America. All rights reserved.
Revised: June 26, 2008