Home
About
Contact Us
Our System
Instructors
Grandmaster Art Hinkelbein
Master Melissa Hinkelbein
Programs
Little Ninjas Program (Ages 4-5)
Children’s Martial Arts (Ages 6-8)
Youth (Ages 9-12) & Teen Martial Arts
Adult Martial Arts
Beginner Trial Offers
Events
Calendar
Home
About
Our System
Instructors
Grandmaster Art Hinkelbein
Master Melissa Hinkelbein
Master Ronika Eckart
Mr. Colin Thompson
Programs
Beginner Trial Offers
Little Ninjas Program (Ages 4-5)
Kids Program (Ages 6-8)
Youth (Ages 9-12) & Teen Martial Arts
Adult Martial Arts
Contact Us
Events
Calendar
Adult Information & Goal Assessment
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Birth Date
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Phone
*
United States +1
United States
+1
United Kingdom
+44
Afghanistan
+93
Albania
+355
Algeria
+213
American Samoa
+1
Andorra
+376
Angola
+244
Anguilla
+1
Antigua & Barbuda
+1
Argentina
+54
Armenia
+374
Aruba
+297
Ascension Island
+247
Australia
+61
Austria
+43
Azerbaijan
+994
Bahamas
+1
Bahrain
+973
Bangladesh
+880
Barbados
+1
Belarus
+375
Belgium
+32
Belize
+501
Benin
+229
Bermuda
+1
Bhutan
+975
Bolivia
+591
Bosnia & Herzegovina
+387
Botswana
+267
Brazil
+55
British Indian Ocean Territory
+246
British Virgin Islands
+1
Brunei
+673
Bulgaria
+359
Burkina Faso
+226
Burundi
+257
Cambodia
+855
Cameroon
+237
Canada
+1
Cape Verde
+238
Caribbean Netherlands
+599
Cayman Islands
+1
Central African Republic
+236
Chad
+235
Chile
+56
China
+86
Christmas Island
+61
Cocos (Keeling) Islands
+61
Colombia
+57
Comoros
+269
Congo - Brazzaville
+242
Congo - Kinshasa
+243
Cook Islands
+682
Costa Rica
+506
Croatia
+385
Cuba
+53
Curaçao
+599
Cyprus
+357
Czechia
+420
Côte d’Ivoire
+225
Denmark
+45
Djibouti
+253
Dominica
+1
Dominican Republic
+1
Ecuador
+593
Egypt
+20
El Salvador
+503
Equatorial Guinea
+240
Eritrea
+291
Estonia
+372
Eswatini
+268
Ethiopia
+251
Falkland Islands
+500
Faroe Islands
+298
Fiji
+679
Finland
+358
France
+33
French Guiana
+594
French Polynesia
+689
Gabon
+241
Gambia
+220
Georgia
+995
Germany
+49
Ghana
+233
Gibraltar
+350
Greece
+30
Greenland
+299
Grenada
+1
Guadeloupe
+590
Guam
+1
Guatemala
+502
Guernsey
+44
Guinea
+224
Guinea-Bissau
+245
Guyana
+592
Haiti
+509
Honduras
+504
Hong Kong SAR China
+852
Hungary
+36
Iceland
+354
India
+91
Indonesia
+62
Iran
+98
Iraq
+964
Ireland
+353
Isle of Man
+44
Israel
+972
Italy
+39
Jamaica
+1
Japan
+81
Jersey
+44
Jordan
+962
Kazakhstan
+7
Kenya
+254
Kiribati
+686
Kosovo
+383
Kuwait
+965
Kyrgyzstan
+996
Laos
+856
Latvia
+371
Lebanon
+961
Lesotho
+266
Liberia
+231
Libya
+218
Liechtenstein
+423
Lithuania
+370
Luxembourg
+352
Macao SAR China
+853
Madagascar
+261
Malawi
+265
Malaysia
+60
Maldives
+960
Mali
+223
Malta
+356
Marshall Islands
+692
Martinique
+596
Mauritania
+222
Mauritius
+230
Mayotte
+262
Mexico
+52
Micronesia
+691
Moldova
+373
Monaco
+377
Mongolia
+976
Montenegro
+382
Montserrat
+1
Morocco
+212
Mozambique
+258
Myanmar (Burma)
+95
Namibia
+264
Nauru
+674
Nepal
+977
Netherlands
+31
New Caledonia
+687
New Zealand
+64
Nicaragua
+505
Niger
+227
Nigeria
+234
Niue
+683
Norfolk Island
+672
North Korea
+850
North Macedonia
+389
Northern Mariana Islands
+1
Norway
+47
Oman
+968
Pakistan
+92
Palau
+680
Palestinian Territories
+970
Panama
+507
Papua New Guinea
+675
Paraguay
+595
Peru
+51
Philippines
+63
Poland
+48
Portugal
+351
Puerto Rico
+1
Qatar
+974
Romania
+40
Russia
+7
Rwanda
+250
Réunion
+262
Samoa
+685
San Marino
+378
Saudi Arabia
+966
Senegal
+221
Serbia
+381
Seychelles
+248
Sierra Leone
+232
Singapore
+65
Sint Maarten
+1
Slovakia
+421
Slovenia
+386
Solomon Islands
+677
Somalia
+252
South Africa
+27
South Korea
+82
South Sudan
+211
Spain
+34
Sri Lanka
+94
St. Barthélemy
+590
St. Helena
+290
St. Kitts & Nevis
+1
St. Lucia
+1
St. Martin
+590
St. Pierre & Miquelon
+508
St. Vincent & Grenadines
+1
Sudan
+249
Suriname
+597
Svalbard & Jan Mayen
+47
Sweden
+46
Switzerland
+41
Syria
+963
São Tomé & Príncipe
+239
Taiwan
+886
Tajikistan
+992
Tanzania
+255
Thailand
+66
Timor-Leste
+670
Togo
+228
Tokelau
+690
Tonga
+676
Trinidad & Tobago
+1
Tunisia
+216
Turkey
+90
Turkmenistan
+993
Turks & Caicos Islands
+1
Tuvalu
+688
U.S. Virgin Islands
+1
Uganda
+256
Ukraine
+380
United Arab Emirates
+971
United Kingdom
+44
United States
+1
Uruguay
+598
Uzbekistan
+998
Vanuatu
+678
Vatican City
+39
Venezuela
+58
Vietnam
+84
Wallis & Futuna
+681
Western Sahara
+212
Yemen
+967
Zambia
+260
Zimbabwe
+263
Åland Islands
+358
Email
*
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Goals for training at AHMA
*
Self Defense
Fitness
Socialization
Stress Reduction
Confidence
Discipline
Focus/Concentration
Leadership
Other
What are your other goals?
Previous martial arts experience?
*
Choice 4
Yes
No
What style and how long?
How did you hear about us?
*
Choice 6
Referral
Drive By/Walk In
Search Engine
Social Media
Other
Who can we thank for referring you?
You may voluntarily tell us about any medical conditions, limitations or other information that could be important for us to be aware of.
Emergency Contact
*
First
Last
Emergency Contact Phone
United States +1
United States
+1
United Kingdom
+44
Afghanistan
+93
Albania
+355
Algeria
+213
American Samoa
+1
Andorra
+376
Angola
+244
Anguilla
+1
Antigua & Barbuda
+1
Argentina
+54
Armenia
+374
Aruba
+297
Ascension Island
+247
Australia
+61
Austria
+43
Azerbaijan
+994
Bahamas
+1
Bahrain
+973
Bangladesh
+880
Barbados
+1
Belarus
+375
Belgium
+32
Belize
+501
Benin
+229
Bermuda
+1
Bhutan
+975
Bolivia
+591
Bosnia & Herzegovina
+387
Botswana
+267
Brazil
+55
British Indian Ocean Territory
+246
British Virgin Islands
+1
Brunei
+673
Bulgaria
+359
Burkina Faso
+226
Burundi
+257
Cambodia
+855
Cameroon
+237
Canada
+1
Cape Verde
+238
Caribbean Netherlands
+599
Cayman Islands
+1
Central African Republic
+236
Chad
+235
Chile
+56
China
+86
Christmas Island
+61
Cocos (Keeling) Islands
+61
Colombia
+57
Comoros
+269
Congo - Brazzaville
+242
Congo - Kinshasa
+243
Cook Islands
+682
Costa Rica
+506
Croatia
+385
Cuba
+53
Curaçao
+599
Cyprus
+357
Czechia
+420
Côte d’Ivoire
+225
Denmark
+45
Djibouti
+253
Dominica
+1
Dominican Republic
+1
Ecuador
+593
Egypt
+20
El Salvador
+503
Equatorial Guinea
+240
Eritrea
+291
Estonia
+372
Eswatini
+268
Ethiopia
+251
Falkland Islands
+500
Faroe Islands
+298
Fiji
+679
Finland
+358
France
+33
French Guiana
+594
French Polynesia
+689
Gabon
+241
Gambia
+220
Georgia
+995
Germany
+49
Ghana
+233
Gibraltar
+350
Greece
+30
Greenland
+299
Grenada
+1
Guadeloupe
+590
Guam
+1
Guatemala
+502
Guernsey
+44
Guinea
+224
Guinea-Bissau
+245
Guyana
+592
Haiti
+509
Honduras
+504
Hong Kong SAR China
+852
Hungary
+36
Iceland
+354
India
+91
Indonesia
+62
Iran
+98
Iraq
+964
Ireland
+353
Isle of Man
+44
Israel
+972
Italy
+39
Jamaica
+1
Japan
+81
Jersey
+44
Jordan
+962
Kazakhstan
+7
Kenya
+254
Kiribati
+686
Kosovo
+383
Kuwait
+965
Kyrgyzstan
+996
Laos
+856
Latvia
+371
Lebanon
+961
Lesotho
+266
Liberia
+231
Libya
+218
Liechtenstein
+423
Lithuania
+370
Luxembourg
+352
Macao SAR China
+853
Madagascar
+261
Malawi
+265
Malaysia
+60
Maldives
+960
Mali
+223
Malta
+356
Marshall Islands
+692
Martinique
+596
Mauritania
+222
Mauritius
+230
Mayotte
+262
Mexico
+52
Micronesia
+691
Moldova
+373
Monaco
+377
Mongolia
+976
Montenegro
+382
Montserrat
+1
Morocco
+212
Mozambique
+258
Myanmar (Burma)
+95
Namibia
+264
Nauru
+674
Nepal
+977
Netherlands
+31
New Caledonia
+687
New Zealand
+64
Nicaragua
+505
Niger
+227
Nigeria
+234
Niue
+683
Norfolk Island
+672
North Korea
+850
North Macedonia
+389
Northern Mariana Islands
+1
Norway
+47
Oman
+968
Pakistan
+92
Palau
+680
Palestinian Territories
+970
Panama
+507
Papua New Guinea
+675
Paraguay
+595
Peru
+51
Philippines
+63
Poland
+48
Portugal
+351
Puerto Rico
+1
Qatar
+974
Romania
+40
Russia
+7
Rwanda
+250
Réunion
+262
Samoa
+685
San Marino
+378
Saudi Arabia
+966
Senegal
+221
Serbia
+381
Seychelles
+248
Sierra Leone
+232
Singapore
+65
Sint Maarten
+1
Slovakia
+421
Slovenia
+386
Solomon Islands
+677
Somalia
+252
South Africa
+27
South Korea
+82
South Sudan
+211
Spain
+34
Sri Lanka
+94
St. Barthélemy
+590
St. Helena
+290
St. Kitts & Nevis
+1
St. Lucia
+1
St. Martin
+590
St. Pierre & Miquelon
+508
St. Vincent & Grenadines
+1
Sudan
+249
Suriname
+597
Svalbard & Jan Mayen
+47
Sweden
+46
Switzerland
+41
Syria
+963
São Tomé & Príncipe
+239
Taiwan
+886
Tajikistan
+992
Tanzania
+255
Thailand
+66
Timor-Leste
+670
Togo
+228
Tokelau
+690
Tonga
+676
Trinidad & Tobago
+1
Tunisia
+216
Turkey
+90
Turkmenistan
+993
Turks & Caicos Islands
+1
Tuvalu
+688
U.S. Virgin Islands
+1
Uganda
+256
Ukraine
+380
United Arab Emirates
+971
United Kingdom
+44
United States
+1
Uruguay
+598
Uzbekistan
+998
Vanuatu
+678
Vatican City
+39
Venezuela
+58
Vietnam
+84
Wallis & Futuna
+681
Western Sahara
+212
Yemen
+967
Zambia
+260
Zimbabwe
+263
Åland Islands
+358
Release & Waiver of Liability
*
By checking this box, I certify that I have read and agree to the terms of the release and waiver or liability below.
By agreeing to these terms, I declare myself the aforementioned student or participant, hereby known as the releasor and certify that I am at least 18 years of age.
1. I hereby acknowledge and fully understand that:
a) I should inspect the facilities and equipment to be used and if I believe anything is unsafe, immediately advise the officials of such conditions and refuse to participate in the event(s).
b) There are risks and dangers associated with participation in martial arts and events which could result in bodily injury, partial and/or total disability, paralysis and death.
c) The social and economic losses and/or damages, which could result from these risks and dangers described above, could be severe.
d) These risks and dangers may be causes by the action, inaction or negligence of the participant or the action, inaction or negligence of others, including, but not limited to the Releasee.
e) I am aware of the existence of the risk of participation that may cause injury or illness such as, but not limited to Influenza, MRSA, or COVID-19 that may lead to paralysis or death.
f) There may be other risks not known to me or are not reasonably foreseeable at this time.
2. I accept and assume all risks and responsibility for the losses and/or damages following such injury, disability, paralysis or death, however caused and whether caused in whole or in part by the negligence of the Releasee.
3. I hereby release, waive, discharge and covenant not to sue Art Hinkelbein Martial Arts Academy LLC, the martial arts facility used by the student/participant, including its owners, managers, promoters, lessees or premised used to conduct the martial arts event or program, premises and event inspectors, underwriters, volunteers, consultants and others who give recommendations, directions, or instructions to engage in risk evaluation or loss control activities regarding the martial arts facility or events held at such facility and each of them, their directors, officers, agents, employees, all for purposes herein referred to as “Releasee” from all liability to the Releasor, my personal representatives, assigns, executors, heirs and next to kin for any and all claims or demands therefore on account of any injury, including but not limited to the death of the student/participant or damage to property, arising out of or relating to the event(s) caused or alleged to be caused in whole or in part by the negligence of the Releasee or otherwise.
4. I hereby acknowledge that the activities of the event(s) are very dangerous and involve risk of serious injury and/or death and/or property damage. The Releasor also expressly acknowledges that injuries received may be compounded or increased by negligent rescue operations or procedures of the Releasee.
5. The Releasor further expressly agrees that the forgoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as is permitted by the law of the Province or State in which the event(s) is conducted and that if any portion is held invalid, it is agreed that the balance shall, notwithstanding continue in full legal force and effect.
6. The Releasor executes this waiver and release. If, despite this release, the Releasor makes a claim against the Releasee, the Releasor will reimburse the Releasee for any money which they have paid to the student/participant, or on their behalf, and hold them harmless.
7. By providing my email address I agree to receive emails from AHMA. I grant Art Hinkelbein Martial Arts Academy LLC the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures or video taken of the aforementioned participant to be used in and/or for legally promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social networking sites and other print and digital communications, without payment or any other consideration.
I have read this release and waiver of liability, assumption of risk and indemnity agreement, fully understand it's terms, understand that I have given up substantial rights by agreeing to these terms and conditions and have agreed freely and voluntarily without any inducement, assurance or guarantee being made to me and intend my agreement to be complete and an unconditional release of all liability to the greatest extent allowed by law.
Submit
MENU