Thank you for booking your martial arts class!

Name *

First Name

Last Name

Phone *

(###)

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Emergency Contact Number *

(###)

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1. Has your doctor ever diagnosed you with a heart condition or recommended only medically supervised physical activity? *

Yes

No

2. Do you experience chest pain during physical activity or at rest? *

Yes

No

3. Do you lose balance due to dizziness or lose consciousness? *

Yes

No

4. Do you have any bone, joint, or muscular problems that could be worsened by physical activity? *

Yes

No

5.Are you currently taking any prescribed medication that could affect your ability to participate in martial arts training? *

Yes

No

6. Do you have any chronic medical conditions or illnesses not mentioned above? *

Yes

No

1. Have you had any previous injuries that might impact your ability to train? (e.g., fractures, sprains, concussions) *

Yes

No

2. Are you currently recovering from or undergoing treatment for any injury? *

Yes

No

1. Have you previously trained in martial arts? *

Yes

No

1. Do you identify as neurodiverse (e.g. dyslexia, ADHD, autism)? *

Yes

No

2. Are there any other special considerations or support needs you would like us to be aware of? *

Yes

No

I, the undersigned, certify that the above information is correct to the best of my knowledge. I understand that martial arts training can involve physical activity and, in some cases, contact that may result in injury. I voluntarily assume the risk of participating in this programme and agree to inform Conquest Martial Arts if any changes to my health status occur.

Yes, I agree