New Student Intake Form New Student Intake Form Participant’s Name* First Last Date of Birth* Month Day Year Participant’s Gender* Male Female Guardian's Name (If Applicable) First Last Cell Phone*Email* May We Communicate With You Via Text Message?* Yes No Premier Martial Arts Location*Select LocationLubbock West, TXAbilene - South 14th StreetAbilene, TXAddison, TXAiken, SCAlbuquerque, NMAllandale, TXAnthem/Seven Hills, NVApex, NCArapahoe, COArcadia, AZArden, NCConway, ARArlington Heights, ILArlington (West), TXAshburn, VAAsheville, NCAugusta, GAAustell, GAAventura, FLAurora, OHBardmoor, FLBarker Cypress, TXBear, DEBedford, TXBloomfield, NJBonita Springs, FLBothell, WABountiful, UTBrentwood, PABrighton, COBroken Arrow, OKBrooklyn Heights, NyBrunswick, GABuckhead Central, GABurlington, MACanton, GACarmel, INCentenniel - Lone Tree, COCentral, NECentral Point, ORChambersburg , PAChandler East, AZChapel Hill/Durham, NCNorth Charleston, SCConcord, NCClarksville, TNClermont, FLCoconut Creek, FLColleyville, TXCollierville, TNColumbus, MSConshohocken, PACorpus Christi, TXCottleville, MOCranston, RICreve Coeur, MODavie/Weston, FLDecatur East, GADeerfield, ILDenton South, TXDenville, NJDickinson, TXAustin, TXDoral, FLDraper, UTDruid Hills, GAEast Allen, TXEast Brainerd, TNEast Cobb, GAEast Edmond, OKEast Marietta, GAElk Grove, CAEncinitas, CAEncino, CAEverett-Millcreek, WAFairlawn, OHFarragut, TNFayetteville, ARFiesta Trails, TXFishhawk, FLFleming Island, FLFlower Mound, TXFolsom, CAFort Walton Beach, FLForty Fort, PAFrisco, TXFt Wayne, INGainesville, VAGarner, NCFort Wayne, INGilbert, AZGlen Mills, PAGrand Prairie, TXGrand Rapids, MIGreeley, COGreenville, SCGrovetown, GAHaddon Township, NJHamburg, KYHardin Valley, TNHarlingen, TXHavelock, NCHaverhill, MAHealth Village, MIHelotes, TXHenderson (Green Valley South), NVHighland Creek, NCHingham, MAHinsdale, ILHolly Springs, NCHouston Heights, TXHuntersville, NCHuntingdon Valley, PAIrmo, SCIvy City, DCJacksonville, FLJeffersonville, INJersey Village, TXJohns Creek, GAKaysville, UTKentwood, MIKingwood, TXKnoxville , TNKauai, HILa Vista, NELafayette, COLake Highlands, TXLake Jackson, TXLake Oswego, ORLake Wylie, SCLakeline, TXLakewood Forest, TXLakewood, TXLancaster, PALand O'Lakes, FLLantana, TXLargo, FLLas Vegas, NVLatham, NYLawrence, KSLeague City, TXLeander, TXLebanon, TNLees Summit, MOLewisville / Castlehill, TXLittleton, COLivingston, NJLowry, COLubbock, TXMableton, GAMacedonia, OHMagnolia, TXManassas, VAManchester, MOMaplewood, NJMarietta, GAMarlborough, MAMartinez, GAMarysville , WAMaryville, TNMason, OHMcCalla, ALMckinney/Fairview, TXMechanicsburg, PAMeridian, IDMesa, AZMiddletown, DEMint Hill, NCMission, TXMonroe Township, NJMount Pleasant, SCMt Juliet, TNMurfreesboro, TNMurphy, TXMurrieta, CAMurrysville, PACharlotte, NCNaples, FLNew Braunfels, TXNew Britain, PANoblesville, INNorcross, GANorth Augusta, SCNorth Canton, OHNorth Colorado Springs, CODavidson, NCNorth Kingstown, RINorth Knoxville, TNNorth McAllen, TXNorth Ogden, UTNorth Oklahoma City, OKNorthshore, TNNorton, MAOak Ridge, TNOakdale, PAOdessa, TXOkemos, MIOlathe, KSOmaha, NEOrem, UTOrmond Beach, FLPaducah, KYPalm Valley/Nocatee, FLParadise Valley, AZPark Ridge, NJPearland, TXPembroke Pines, FLPeoria, AZPflugerville, TXPhoenix, AZPhoenixville, PAPlano, TXPlantation, FLPleasant Grove, UTPowder Springs, GAPowell, TNRancho Bernardo, CARandolph, MARaynham , MAEast Wichita, KSRenton, WARichardson, TXRichland, WARichmond, TXHouston River Oaks, TXRiverton, UTRosenberg, TXRound Rock, TXRoyal Oak, MISacramento, CASammamish, WASan Marco, FLSandy Springs, GASanford, FLSanta Clarita Valley, CASaugus, MASavage, MNScarsdale, NYSchertz, TXScituate, RIScottsdale, AZShadow Creek, TXSharon Springs, GAMissouri City Sienna, TXSlidell, LASouth Charlotte, NCSouth Elgin, ILSouth Huntington Beach, CASouth Lexington, KYSouthlake, TXCentennial, COSpring, TXSt. Augustine, FLSt. Charles, MoSt Louis/West End, MOSteele Creek, NCSteiner Ranch, TXSterling Heights, MIStoughton, MASugarland (East), TXSummerwood, TXSuwanee, GASW, INSwampscott, MAThe Woodlands (Gosling), TXThornton Town Center, COThornwood, NYTrophy Club, TXTrumbull, CTTyler, TXUniversity Town Center, FLValley Ranch, TXWarwick, RIWash Park, COWatauga, TXWauwatosa, WIWest Cary, NCWest Katy/Fulshear, TXWest Linn, ORWest Loop, ILWest Omaha, NEWest Valley City, UTWestlake, CAWichita, KSWildwood, MOWoodbridge, VAWoodforest, TXWyomissing, PAAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 1. How Did You Happen To Hear About Us? Website Print Ad Social Media Sign/Drive By Radio/T.V. Direct Mail Birthday Party Promotional Booth Referral Other (If Referral) Referred By (If Other) Please State How You Heard About Us 2. Do You Live In The Area?* Yes No Do You Plan To Remain In The Area?* Yes No 3. Are You Or Your Child In Good Health With No Physical Problems?* Yes No Pleas List Any Medical Conditions We Should Be Aware Of4. Is Your Schedule Such That You Can Arrange For You Or Your Child To Take Lessons Twice a Week? Yes No 5. Do You Or Your Child Have Any Previous Martial Arts Experience? Yes No 6. Do You Feel Your Signficant Would Support Your Decision In Getting You Or Your Child Enrolled Provided Our Program Fits Your Needs? Yes No 7. On A Scale Of 1 - 10, 1 Being Low and 10 Being Great, Please Rate You Or Your Child on the Following:Focus/Concentration 1 2 3 4 5 6 7 8 9 10 Confidence/Self-Image 1 2 3 4 5 6 7 8 9 10 Respect To Others 1 2 3 4 5 6 7 8 9 10 Fitness/Activity Level 1 2 3 4 5 6 7 8 9 10 Leadership (Not A Follower, Doesn't Succumb To Peer Pressure) 1 2 3 4 5 6 7 8 9 10 8. Would You Like To Invite Someone To Take A Free Lesson With You?* Yes No Friend's Name Friend's PhoneFriend's Email In consideration for my or my child's attendance and participation in the martial arts training offered by Premier Martial Arts, I acknowledge the existence of certain inherent risks in this type of training and hereby agree to assume all risks. I further relieve Premier Franchising Group LLC, Premier Martial Arts International Inc., the school, it's management, assigned staff, and fellow students from liability resulting from bodily injury, virus, any type of contagious sickness, or loss, whether personal belongings or bodily injury. I understand that member images may be used for promotional or training purposes. I agree that I or my child will not attend any event at any time when I or my child believes that they might be ill, is experiencing any symptoms of illness, or has been exposed to a person or persons known to be infected with a contagious illness. I also hereby state that I or my child is physically fit to take the prescribed course of instruction and does so of my own free will.Guardian Or Adult Student Signature*CAPTCHA
