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Honor, Integrity, Service UMA

(904) 803-2572

Medical Information - All medical information will be kept confidential It is very important that we are aware of any medical conditions you or your child may have, especially any that may affect you or your child's training.

Have you consulted a physician prior to entering this program? *

Yes No

Do they have any of the following? *

Asthma/Bronchitis Previous Broken Bones Heart Conditions/Arrhythmia Free Bladder Back/Neck Problems Diabetes Allergies

Does the student applying have any medical conditions that may affect their training? *

Yes No

Please check any that apply. *

ADD ADHD OCD ODD Autism or any other Autism Spectrum Disorder

Comments and special instructions *

Please give necessary information concering any item(s) circled above

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Contact United Martial Arts at (904)762-9687

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