Required Fields*
*Date: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2008 2009
*Name: *Age: *E-mail: *Home Phone: Cell Phone:
Address: City: State: NJ PA DE Occupation: Employer: How Long:
*Who are the lessons for: *Age: *Relation to you: * How did you find out about us Surfing the web Flyer Business Card Phone Book Other

Previous Experience.
Have you trained in Martial Arts Before: Yes: No: If yes where? How Long? Rank?
Have you done KickBoxing or Pilates before: Yes No If so were? How Long?

Your Goals:
What do you want to accomplish from your training here? Check all that apply.

Fitness | Weight loss | Muscular Strength | Cardiovascular | Increased Flexibility | Stress Relief
Self-Disipline | Self-Confidence | Self-Defense | Any Others?

If you are accepted how long are you willing to work to achieve your goals?

Any Questions about Training? Any Medical Conditions that would limit your ability to train?

Are you currently involved in the fitness industry? Yes No If yes Were? How Long?

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