CBBA Adult Evaluation Form 2020
Please complete the following form to the best of your ability. Rest assured, all information will be kept strictly confidential.
Student's First Name *
Student's Last Name *
Street Number and Name *
City/Town
Province
Country
Postal Code
Main Contact
Main Contact Number
555-444-1234
Main Contact Email
Spouse / Alternate Contact Name
Spouse / Alternate Contact Number
555-444-1234
Spouse / Alternate Contact Email
How did you hear about us?
If you were referred by someone, who can we thank?
Date Of Birth
MM
/
DD
/
YYYY
Gender
Emergency Contact Name
Emergency Contact Phone
555-444-1234
Marital Status
If Married will your spouse be taking class with you?
Clear selection
Will you be able to attend classes twice per week?
Clear selection
Are there any physical or learning disabilities that we should be aware of?
Have you ever trained the martial arts before?
Clear selection
If Yes, which style?
Are you going to be living in the area for at least 1 year?
Clear selection
What made you want to try our Academy?
Do you have a place to practice outside of the Academy?
Clear selection
Which programs are you most interested in?
Check the boxes that best describe you
What other sports/activities do you participate in? Please list.
Please select the benefits you would like to receive from training at our academy.
Submit
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