Empowered Martial Arts – Adult Trial Registration Form

Name *

First

Last

Date of birth *

Age *

Gender *

Male
Female

Preferred trial class day/s

Wednesday
Friday

How did you hear about us?

Social Media (Facebook/Instagram)
Google Search
Family/Friends
Flyers/Posters/Van
School Newsletter
Other

Have you ever been restricted or denied from participating in physical activity, sport or martial arts for any reason? *

Yes
No

Do you have any on-going medical conditions? *

Yes (please specify below)
No

Details of on-going medical condition:

Have you ever had an injury to a bone, muscle, ligament or tendon that has caused him/her to not participate in physical activity, sport or martial arts? *

Yes (please specify below)
No

Injury type and restrictions (if any):

Have you ever felt faint or had spells of dizziness during physical activity/exercise that causes him/her to lose balance? *

Yes
No

Do you have any muscle, bone or joint pain or soreness that is made worse by particular types of activity? *

Yes
No

Is there any other medical or physical conditions/limitations that we should be made aware of before you participates in our martial arts classes? (write 'None' if none) *

Some medical conditions may require the provision of a medical clearance prior to training. I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. By ticking the box, I hereby agree to all terms and conditions as mentioned and release Empowered Martial Arts and all instructors and representatives from any liability, for personal injury which may occur to myself during my participation in classes. *

I agree to the Terms and Conditions above.

Today's date: *

Mobile number *

Email *

28190

Contact

in**@em******************.au
0404 562 562

Address

77-123 Jacksons Road
Noble Park North VIC 3174