MIXED MARTIAL ARTS, MMA PLAINVIEW NY LONG ISLAND

Must be 18 or over to attend, anyone under 18 must be accompanied by a parent or guardian for the first class in order to sign a release form. Parent or Guardian must present a valid State I.D. to register minor.

Please bring a valid State I.D. which is required for the first class. Trial class is FREE.


First Name:
Last Name:
Date of Birth: Month, Day, Year
Email:
Home Address:
City:
Zip code
Home phone:
Work Phone:
Cell Phone:
Request to be allowed to participate in class	Teens 13-18 yrs old Adults 18 and over
How did you hear about us? Please Tell
If referred, please list their name here. One name only.
Will you be living in the area for the next 12 months?	Yes No
Any medical info. we need to know?	Yes No
Have you ever taken a class with us Before?	Yes No
Select as many reasons for enrolling in class as are pertinent.	Confidence Weight loss Health Fun Toning Stress relief Discipline Self Defense
Pertinent medical info:
Short term goals
Long term goals
Day and Time you will be attending your first class:

Any Martial Arts, Cardio kick and or boxing experience?	Yes No
Parents Information if under 18 years of age.
Mom's Full Name
Mom's Cell Number
Dad's Full Name
Dad's Cell Number
Parents must come in to sign a release form the first time. We can not send it to you. Parents please bring valid I.D.

NOTICE:

M.A.X. M.M.A. urges all persons to obtain a physical examination from their physician prior to taking any Martial Arts or Fitness class. In recognition on the possible dangers connected with any physical activity, participant(s) hereby knowingly and voluntarily waive any right by filing this form to cause action of any kind whatsoever arising as the result of such activity from which any liability may or could occur to M.A.X. M.M.A., its officers, employees or instructors. I give permission to the person listed to take class. I also give permission to M.A.X. M.M.A. to have myself or child taken to the hospital in case of an emergency.

Request to be allowed to participate in class

NOTICE: