Adult Application

Student Information:

First name:
Last name:
Gender:
Date of birth:
Email address:
Phone number:
Address:
City/Town:
State:
Zip:

Emergency Contact Information:

First name:
Last name:
Relationship:
Phone number:

Student Questionnaire:

1. Why are you interested in learning martial arts?  I want to learn to defend myself I want to gain self-confidence in my abilities I want to lose a little weight and strengthen my body I want to be involved in a beneficial athletic program I want to improve my self-control and self-discipline
2. How did you hear about our studio?
3. What does a black belt signify to you?
4. If you are accepted, would you set a goal to become a black belt someday?
5. What is the most important goal in your life?
6. Can you practice on your own for at least 30 minutes a day?
7. Have you trained in the martial arts before?  Yes No
7a. If yes to question 7. What style? How long did you train? When did you last train?
8. How would you rate your health?  Excellent Good Average Poor
8a. If you have any health problems, please list them:
9. What do you value the most at this time?