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Guardian / Emergency Contact Info
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Email
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Your email
First Name (e.g., Jennifer)
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Your answer
Prefer to be called (e.g., Jen)
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Your answer
Last Name
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Your answer
Phone
*
Your answer
Willing and able to receive texts?
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No
Do you want to get notified about new offerings and classes?
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Name of Child (or Children) in the Program
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Your answer
Relation to Child (or Children)
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Mom
Dad
Stepmom
Stepdad
Grandma
Grandpa
Uncle
Aunt
Other:
Referred By (How did you hear about our program? Check all that apply)
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Word of Mouth (please also check "Other" and give the name of the person who referred you and how you know them. Thanks!)
Google Search
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Other:
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What interests you most about the Mindful Martial Arts program?
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Your answer
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