Ferocity Taekwondo | ATA Affiliated Academy

I am completing this form for a minor

Parent/Guardian Name(s)

Student Information

Student’s Name

Age

DOB

Sex

I would like to register another student

Student’s Name (2)

Age

DOB

Sex

I would like to register another student

Student’s Name (3)

Age

DOB

Sex

Contact Information

Contact Person

Contact’s Phone

Contact DOB

Address

City

State

Zip

Home Phone

Cell Phone

E-Mail

Participation Waiver

In consideration for my attendance and participation in the Martial Arts and/or Self-Defense training offered by Ferocity ATA Martial Arts, I, the student/parent, acknowledge the existence of certain inherent risks in this type of training and hereby agree to assume all risks.

I further relieve the school, its management, all affiliates, including Krav Maga Worldwide Inc, Krav Maga Association of America, and American Taekwondo Association, assigned staff, and fellow students from any liability resulting from loss or damages, whether personal belongings or bodily injury.

I also hereby state that my child or myself is physically fit to take the prescribed course of instruction and do so of my own free will in exchange for the agreed upon fee. I understand there is a no refund policy on any monies I will pay Ferocity ATA Martial Arts.

I have read and agree to the participation waiver.

Name

Signature Date

Goals and Referrals

What specifically would you like to accomplish in the martial arts program?

How did you hear about us?

Do you have anyone that you would like to refer us to?

Referral Name

Referral Phone #

Referral Name

Referral Phone #

Medical / Diagnosis Concerns

Are there any medical or diagnosis concerns that we should be aware of? Example: seizures, ADD, asthma, autism, etc.

Program Priorities

Please rank each area in order of importance to you: 1 = most important, 4 = less important.

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