RVCS 5 Animals Frolics Sports Qigong for Kids RegistrationPlease enable JavaScript in your browser to complete this form.Student InformationName *FirstLastDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name of SchoolDoes the Student Have Previous Martial Arts Experience? *YesNoName of Martial Arts SchoolIf the student was ranked, what belt did they earn?Goals *Please share with us any specific goals you have for your child’s participation in our program.Parent/Guardian InformationName *FirstLastPhone *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Emergency ContactSame as AboveYesNoName *FirstLastPhone *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Are There Medical Concerns We Should Be Aware Of?YesNoMedical ConcernsPlease let us know if there is anything else you'd like us to be aware of or if you have any specific questions for us.Consent for photography. *I agree to have my child’s picture taken.I agree, but I’d like their face blurred out so they cannot be identified.I agree but only from behind.I do not agree.We occasionally take pictures for marketing purposes to be used in digital and print collateral. We respect your choices for digital privacy.Terms and Conditions *AgreeI understand that Qigong, Tai Chi and Wudang Kung Fu are martial arts and that while instructors will prioritize the safety of all students, injuries are possible. I agree to not hold Great Bay Tai Chi MA, Internal Arts New England, or any instructor liable for any injuries that may occur during the course of training.Submit
