Date:
Student ID:
Child's First Name:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Sex:
Date of Birth:
Age:
Father's Name
Occupation:
Work Phone
Work E-mail:
Employer Address:
Is your child in good health and with no physical problems?
If not, please explain:
Previous Experience:
If yes, describe:
How did you first hear of American Academy of Self defense?
*Referred by:
*Other Please specify:
Consider the following reasons to learn the Martial Arts and number them in their order of importance to your child:
Self Defense:
Self Confidence:
Self Control:
Self Discipline:
Physical Fitness:
Weight Control:
Is there any reason you as a parent cannot observe at least 2 of your child's classes per month?
If yes, please explain:
Have you read the Student Creed?
Do you agree with our Student Creed?
What does Black Belt mean to you?
Are you and your child willing to set a goal to develop your child's mental discipline and physical fitness?
Will you be living in this area for at least one year?
Can your child commit to at least 10 minutes DAILY TO PRACTICE AT HOME?
What are your child's 2 best qualities?
If your child is accepted in our program, are you and your child mentally prepared to follow the rules and philosophy of Martial Arts discipline?
The undersigned student or parent/guardian understands the risk of studying Martial Arts and hereby releases American Academy of Self Defense, all instructors and all other students of American Academy of Self Defense from any and all liabilities for any type of injuries and/or loss sustained while training, studying, practicing, or in the application of Martial Arts or Karate. The undersigned also states that he/she is in good physical condition and know of no reason why he/she cannot study and participate in Martial Arts. The undersigned understands that American Academy of Self Defense does not offer refunds.
In the event of an emergency, I hereby authorize any licensed medical personnel to perform any accepted medical procedure deemed necessary and agree to bear the expense of any treatment.
THE UNDERSIGNED ALSO UNDERSTANDS THAT IT IS MANDATORY TO ATTEND AT LEAST TWO CLASSES A WEEK AND TO ATTEND STRIPE TESTS AND BELT PROMOTIONS AS SCHEDULED
Signature:
Date:
In case of an emergency, call:
At:
*Home E-mail:
Work E-mail:
CONGRATULATIONS ON YOUR DECISION TO TAKE THE FIRST STEP, NOT ONLY ON BECOMING A BLACK BELT, BUT TO BE SUCCESSFUL IN EVERYTHING YOU DO!
WELCOME TO
Junior Student Application
CLICK ON THE SEND BUTTON TO TRANSMIT YOUR APPLICATION TO SIFU RICK
Will you support your child to apply his/her mind, heart and body to develop knowledge, honesty and strength, which are the central themes of Martial Arts philosophy?
Mother's Name:
Occupation:
Employer Address: