Student's Name: *

First Name

Last Name

Male

Female

Other

DOB: *

MM

DD

YYYY

Parent or Guardian's Name (if under 18):

First Name

Last Name

Phone Number:

(###)

###

####

How did you find us ? *

Google or other search engine

Yelp

*Referral: (Please print name in "Message to Coach Ethan" and submit)

*Other: (Please tell us in "Message to Coach Ethan" and submit)

What Are Your Goals In Joining NIU Academy? *

multiple choices

Build Confidence & Self-Discipline

Lose Weight & Build Strength

Competition & Tournament

Reduce Stress

Which Program You Plan To Join? *

NIU Basic Program - 1 class a week

NIU Practical Program - 2 classes a week

Private Classes - flexible hours

Have You Read the Academy Program Policies? *

YES

Have You Filled Out the Liability Waivers? *

YES