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Let me introduce myself, my name is Professor Tim Credeur. I am the owner and Head
Instructor at Gladiators Academy of Lafayette. We teach of variety of reality based martial arts
at our Academy and over the years we have produced multiple World Class Athletes in Muay
Thai Kickboxing, Gracie (Brazilian) Jiu-Jitsu and Mixed Martial Arts.
Over the years we have seen a need to start a program for financially challenged
College Students, Young Adults and Motivated Prospects who possess the desire to train but
lack the financial resources. In the spirit of helping our fellow man we have created the
Student Ambassador Program to give young talent a chance!
This program is offered to people who make it through a fairly rigorous application,
interview and background check. Those who are accepted will be required to invest a very
minimal monthly program fee and the rest of their tuition will be covered via our Ambassador
Program Responsibilities. After receiving all of the applications we will be contacting only 20
candidates for acceptance into the program.
Please fill out the attached Application and email it back to me at the following email,
tim@gladiatorsla.com! We look forward to hearing from you and we wish you all the best in
your future and in your endeavors!
Professor Tim Credeur
Gladiators Academy of Lafayette Student Ambassador Program Application
Student Information
First Name: Last Name: Middle Initial:
Date of Birth: Sex: Occupation:
Address:
City: State: Zip Code:
Home Phone: Cell Phone:
Email: Married: O Yes O No
Children over age 4:
O Yes O No
Parent/Guardian/Spouse Contact Information
Primary Contact Name: Relationship: Occupation: Phone Number:
Secondary Contact Name: Relationship: Occupation: Phone Number:
Emergency Contact Name: Relationship: Occupation: Phone Number:
Desired Benefits
Mental
O Become Goal Orientated
O Finish What I Start
O Strong Focus
O Strong Self Discipline
O Leadership
O Mental Toughness
O Strong Work Ethic
O High Self Esteem
O High Self Confidence
O Structured Lifestyle
O Mental Relaxation
O Inner Peace
O Philosophy
Physical
O Fitness
O Healthy Body Fat%
O Weight Control
O Muscle Tone
O More Muscle Mass
O Muscular Strength
O Muscular Stamina
O Strong Cardiovascular
O Healthier Diet & Lifestyle
O More Energy
O More Flexibility
O Relaxation
O Stress Relief
Skill
O Self Defense Skills
O Competition Skills
O The Martial Arts
O Explosive Power
O Balance & Coordination
O Reaction Time
Extra Benefits
O Work
O School
O Family
O Parenting
O Role Model
O Healthy Hobby
O Martial Arts Career
Medical Information
Medical History:
O Asthma
O Bleeding Disorder
O Diabetic
O Seizures
O Multiple Concussions
O High Blood Pressure
O Heart Conditions
O Back Problems
O Shoulder/Elbow/Knee Injury
O None
Current Medications:
__________________________
__________________________
__________________________
Allergic Reactions:
__________________________
__________________________
__________________________
Physical Limitations:
__________________________
__________________________
__________________________
Other:
__________________________
__________________________
__________________________
For student:________________________________________________
RELEASE AND WAIVER OF LIABILITY
I, the undersigned hereby waive all claims against any and all persons associated with the
Gladiators Academy of Lafayette LLC. I understand that I am participating in a martial
art which has body contact. I understand that this form of martial arts involves choke
holds, arm locks, neck cranks, ankle locks, throws, slams, punches, kicks, elbows, knees,
and such which could potentially cause serious injury or even death. I assume full
responsibility for all my actions during and connected to the above organization. I
understand the risk of participating in this form of martial arts training and hereby release
the Gladiators Academy of Lafayette LLC and all of its agents, employees and associates
of and from any and all liability, claims, demands, actions, medical bills, and causes of
action whatsoever arising out of or relating to any negligent or other act or omission,
and/or any loss, damage, or injury, including death, that may be sustained by the
undersigned or any property of the undersigned in participating in this form of training.
I, the undersigned also state that I am in good physical condition and know of no reason
why I can not train in this form of training. I understand that in case of emergency, I
hereby authorize any licensed medical personnel to perform any accepted medical
assistance deemed necessary and I agree to bear the expense of any such treatment. As
additional consideration for training at the Gladiators Academy of Lafayette LLC, I agree
that my attendance and/or performance at the academy and abroad at events and such
may be photographed, filmed and/or taped and used by the Gladiators Academy of
Lafayette LLC for marketing purposes and I authorize the use of my image and I waive
any compensation thereof even if I discontinue my training at the Gladiators Academy
of Lafayette LLC. I acknowledge that I would like to receive correspondence from the
academy via telephone, mail, and email. I, the undersigned, being duly aware of the risks
and hazards inherent upon participating in this form of martial arts agree to all its rules,
terms, and conditions. I acknowledge that I have received a copy of the Gladiators
Academy of Lafayette LLC rules and sparring rules, have read them, understand them,
and agree to honor and obey them. I understand that disobeying the rules may, at the
instructors discretion, result in suspension or expulsion from the and that I will not be
entitled to a refund and if expelled must pay the remainder of my Gladiators Academy of
Lafayette LLC contract if one has been signed. In signing the foregoing release, the
undersigned hereby acknowledges and represents: that he/she has read the foregoing
release, understands it and signs it voluntarily; that he/she is over 18 years of age and of
sound mind. If under 18, parent/legal guardian in signing this release agrees to all its
terms and conditions.
Print Name:______________________________________
(Parent/Legal Guardian if under 18 years of age)
Signed:__________________________________________ Date:_________________
(Parent/Legal Guardian if under 18 years of age)
Gladiators Academy Student Ambassador Program Interview Sheet
1. How did you hear about us? Radio TV Mail-out Flyer Yellow-Pages Sign Drove-by
Internet Referral (______________________)
2. Do you live in the area? Yes No
If not from the area, do you have any friends from the area? Yes No
Name: __________________ Phone:__________________________ Email: _______________________
3. What is your interest in training at Gladiators? ______________________________________________
___________________________________________________________________________________
4. Have you ever trained before? If yes please fill out below info Yes No
Name: _____________________ Phone:_______________________ Email: _______________________
5. Are you currently exercising? Yes No Activity:____________________________
Day(s): M T W R F S S Time(s): ___________________________________
6. What days of the week and times are good for you to train/workout?
Day(s): M T W R F S S Time(s): ___________________________________
7. Do you have martial arts experience? Yes No
8. If YES, are you still training? Yes No (If NO, why did you stop training?)
Likes: _________________________________________________________________
Dislikes:_ ______________________________________________________________
9. How long have you been interested in learning martial arts?
Not too long A few months Over 1 year
10. What is the most important benefit you want to get out of our martial arts program?
______________________________________________________________________________________
11. By what date would you like to see these benefits take place? _________________________________
12. Is earning a Black Belt in Brazilian Jiu-Jitsu one of your goals? Yes No
13. If Yes, do you accept that will take a minimum of four years? Yes No
14. What do you like about our Academy or Instructors? _________________________________________
15. Do you think your significant other would support your decision to learn martial arts and get in shape?
Yes No
16. What has stopped you from getting started in a martial arts program in the past?
______________________________________________________________________________________
17. Is this still an issue? __________________________________________________________________
18. At what day and time would you like to come in for your first group class?
19. Are you willing to accept the financial responsibility for your training through the student ambassador program?
a.) Are you willing to participate in Grassroots Marketing Efforts? ________ Yes __________No
b.) Are you willing to donate monthly volunteer hours? __________ Yes _________No
c.) Are you willing to give your personal guarantee to participate in this program for 1 year? ______ Yes _____No
d.) Are you capable of taking direction and answering to an authority figure? ______Yes _______No
Office Use ONLY: Ready for Class: ___ Yes ___ No
If No, give reason(s):
_________________________________________________________________
Recommended Program and Class Section:
______________________________________________________________
Date: _____/_____/_______
Consultant: ________________________________________
Shirt Size: Small Medium Large X-Large XX-Large XXX-Large
Judo Gi Size: 000 00 0 1 2 3 4 5 6 7
8
MMA Glove Size: R L XL Boxing Glove Size: Women/Kids Mens
Shin Guards: R L XL Head Gear: S M L XL Knee Pads: M
L XL
Groin Cup: S M L XL Would like Wrestling Shoes? Yes No
What Size?_____