Intro Capoeira Class Registration
Which class are you or your child taking?
Kids Class I (Ages 3 to 6 years old)
Kids Class II (Ages 8 years old and up)
Adults Intro Class @ 4M Fitness
First Name (Parent/Guardian if under 18yrs old)
Last Name (Parent/Guardian if under 18yrs old)
Prefer Not To Say
Child's Name, age and gender
Please list any physical limitations and/or developmental/learning needs.
Do you have any of the following:
High Blood Pressure
Allergies (Please list) __________________________________________
None of the above.
What made you want to learn capoeira?
Have you studied capoeira before? If yes, for long and where.
What are you looking gain and/or learn from capoeira?
How did you hear about this class?
Referral (Please list their name)____________________________________
Charlotte On The Cheap
Other (Please list)_________________________________________________
I authorize the verification of the information provided on this form is correct. I understand that this information is for recorded purposes only. Please date and sign below if you are the parent and/or legal guardian. (Print name and date)
Send me a copy of my responses.
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