Freedom Martial Arts & Fitness Online Registration

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We are committed to providing exceptional service and meaningful connections. If you have any questions regarding the registration process, we are happy to help . . . simply contact us at 765-234-0043 ext. 1.

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Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)

Discount Code

Parent Goals for Student(s):*

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Student Goals

Make sure to download our App: The Center by Combat Ministries

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Student Goals

Make sure to download our App: The Center by Combat Ministries

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Student Goals

Make sure to download our App: The Center by Combat Ministries

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Student Goals

Make sure to download our App: The Center by Combat Ministries

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Student Goals

Make sure to download our App: The Center by Combat Ministries

Enroll in Classes

Select Class *

Add Another Student

Required Policies

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Questions or Concerns

Comments

Payment Information

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Card Number

Exp Month

Exp Year

Card Nickname

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Address Line 1

Address Line 2

City

State

Zip

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

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Student #3 (Show-Hide Details)

Additional Info

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Student #4 (Show-Hide Details)

Additional Info

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Student #5 (Show-Hide Details)

Additional Info

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Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

eCheck/Bank Draft

Required Policies

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