Guest's Name *

If more than one guest please add additional name(s) and age(s) in the message area below

First Name

Last Name

Attending parent / legal guardian name (if applicable)

First Name

Last Name

Cell phone *

(###)

###

####

How'd you hear about LEVEL 3? *

Poster / Flyer

Doorhanger

Drive by

Walk By

Google / Internet search

Yelp

Facebook / Instagram

NextDoor

Online - other

Referred

Advertisement

Community event

Auction / Fundraiser

Gift certificate

Other

Program of interest? *

Check all that apply

Jiu-Jitsu (adults 15 & up)

Adult Martial Arts & Self-Defense

Women's Self-Defense (ages 15+)

Junior Martial Athletes (ages 11 - 14)

Champion Children (ages 7 - 10)

Tiny Tigers (ages 5 & 6)

Little Leopards (ages 3 & 4)

Your goals (check all that apply)

Self-defense

Confidence

Physical conditioning (endurance, cardio, strength, flexibility)

Stress relief

Focus & discipline

Academic improvement

Sleep improvement

Achieve Black Belt

Hobby - just for fun

Referring student's name (if applicable)

First Name

Last Name

Scheduled class date

Enter the requested date of the class you'd like to attend. Must be confirmed by L3MAP before you attend.

MM

DD

YYYY

Waiver release *

By checking here, I, the applicant, on behalf or myself, family members, heirs, executors, and other persons of which I am related or connected to in a personal and/or professional manner, hereby release and hold harmless LEVEL 3 Martial Arts Performance (L3MAP), the instructors, all participants, and any related entities, for any injury or loss to my person or property arising out of or in connection with my participation or martial arts fitness and self defense training, speciality events, or other activities in a public, group, and/or private instructional format, notwithstanding that the same may have been contributed to or occasioned by the negligence of L3MAP or others. I realize I am responsible for my own safety and the safety of others around me. If injury occurs, I agree to immediately report the injury to the instructor so that if necessary, L3MAP and/or related representatives shall be authorized to obtain medical treatment as may be necessary and appropriate in emergency circumstances. I also agree I will train safely and respectfully without malice and that intentionally harming another person during my training may be punishable to the fullest extent of the law and that remedies may be sought. I confirm that I have not recently been diagnosed with or have symptoms of any contractible illness including COVID-19 nor have I had contact with someone who is ill with said illnesses. I agree to follow all safety policies and etiquette while engaging in all L3MAP activities. I/WE are choosing at our own risk to participate in an activity considered "higher-risk" during the ongoing pandemic and accept all responsibility for any injuries, sickness, damages, or death to myself or my family that may occur as a result of said participation. If my actions during my visit cause damages to the L3MAP operation, brand, its instructors, or its members I accept full responsibility for all remedies that may be sought.

Responsible party name *

By entering your full name here you agree you are the responsible party age 18 or older and are permitted to agree to the above waiver and that the information you provided is true and correct.

First Name

Last Name