Personal Info Form

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76 Progress Drive

Suite 238

Stamford, CT 06902

203-978-3696

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Personal Information

Participant First Name

Participant Last Name

Participant Birth Date

Parent First Name (if under 18)

Parent Last Name (if under 18)

Street Address

City

Region/State/Province

Postal / Zip code

Phone

By providing your email address, you consent to receiving emails regarding gym activities.

Check the activities you have done in the past:

Boxing

Kickboxing

BJJ

Other

Do you currently belong to another health club/gym?

Yes

Check the type of results you wish to obtain:

Stamina

Strength

Self-Confidence

Weight Loss

If yes, where and for how long?

Do you plan to stay in the area?

Yes

Were you able to achieve your goals with your previous workout routine?

Yes

Are you currently on a diet plan?

Yes

If yes, what kind and for how long?

How long have you thought about starting Brazilian Jiu Jitsu?

Why are you interested in the Carlson Gracie Team?

Are there any physical/emotional condition that would hinder you from participating in a Brazilian Jiu Jitsu program?

Yes

How committed are you to reaching your goals?

Not Very CommittedNot CommittedSomewhat CommittedCommittedExtremely Committed

PERSONAL TRAINING - CORPORATE FITNESS - NUTRITIONAL ADVICE - WEIGHT LOSS - MUSCLE TONE - CORE STRENGTH - POSTURE CORRECTION - CARDIO FITNESS

76 Progress Drive

Suite 238

Stamford, CT 06902

203-978-3696

bjjstamfordct@gmail.com

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