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Student Evaluation Form 2020
Please complete the following form to the best of your ability. Rest assured, all information will be kept strictly confidential. Kindly fill out one per student
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Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Street Number and Name
*
Your answer
City/Town
Your answer
Postal Coda
Your answer
Country
Your answer
Postal Code
Your answer
Main Contact Number (Cellular)
Your answer
Main Contact Email
joesmith@me.com
Your answer
Spouse / Alternate Contact Name
Your answer
Spouse / Alternate Contact Number
555-444-1234
Your answer
Spouse / Alternate Contact Email
joesmith@me.com
Your answer
How did you hear about us?
Choose
Referral
Social Media - Instagram
Social Media - Facebook
Social Media - Other
Birthday Party
Road Sign
Website
Buddy Day
Family Member
Newspaper
From Another Business
Other
If you were referred by someone, who can we thank?
Your answer
Date Of Birth
MM
/
DD
/
YYYY
Gender
Choose
Male
Female
Other
Emergency Contact Name
Your answer
Emergency Contact Phone
555-444-1234
Your answer
Marital Status
Choose
Single
Married
Divorced
Widowed
Seperated
If Married will your spouse be taking class with you?
Yes
No
Maybe
Clear selection
Will you be able to attend classes twice per week?
Yes
No
Maybe
Clear selection
Are there any physical or learning disabilities that we should be aware of?
Your answer
Have you ever trained the martial arts before?
Yes
No
Clear selection
If Yes, which style?
Your answer
Are you going to be living in the area for at least 1 year?
Yes
No
Clear selection
What made you want to try our Academy?
Your answer
Do you have a place to practice outside of the Academy?
Yes
No
Clear selection
Which programs are you most interested in?
Adult Karate
Adult Jiu Jitsu
MMA Strength and Conditioning
Check the boxes that best describe you
Shy
Even Tempered
Out-Going
Assertive
Confident
Hot Headed
Highly Motivated
Easy Going
Introverted
Perfectionist
Cocky
Other:
What other sports/activities do you participate in? Please list.
Your answer
Please select the benefits you would like to receive from training at our academy.
Physical Fitness
Self-confidence
Self-defense
Co-ordination
Positive Attitude
Discipline
Motivation and Focus
Self-Discipline
Stress Relief
Better Concentration
Weight Control
Athletic Skill
More Energy
Other:
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