Do you think your child can bring his/her grades up
to a "B" average or above before attaining the rank of Black Belt?
CONGRATULATIONS ON YOUR DECISION FOR YOUR CHILD TO TAKE THE FIRST STEP NOT ONLY IN
BECOMING A BLACK BELT, BUT TO BE SUCCESSFUL IN EVERYTHING YOUR CHILD DOES!
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
Our academic policy for a young Black Belt is a "C" average or above.

Self Discipline
Consider the following reasons to learn the Martial Arts, and number them in their order of importance to your child.
How did you first hear of American Academy of Self Defence?
Student ID:
Junior Student Application & Questionaire
Date:
Childs First Name:
Last Name:
Address & Apt #:
City, State, & Zip
Home Phone:
Gender:
Date of Birth:
Age:
Father's Name
Work Phone
Employer Address:
City
Zip
Mother's Name:
Employer
Work Phone
Is your child in good health and with no physical condition/problems?
If no, please explain:
Have you had any previous Martial Arts experience?
If yes, please describe:
Referred by:
Please specify:
Self Defence
Self Confidence
Weight Control
Self Control
Physical Fitness
The undersigned student understands the risk of studying Martial Arts and hereby releases American Academy of Self Defence, all instructors and
all other students of  American Academy of Self Defence from any and all liabilities for any type of injuries of 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 Defence 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 such treatment.
Is there any reason your child cannot take lessons at an average of twice per week?
If yes, please explain:
Do you agree with our 7 Home Rules For Children?
What does a 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 PRACTICE AT HOME?
In your opinion, what are your child's 2 best qualities?
If your child is accepted into our program,
are you and your child mentally prepared to follow the rules and philosophy of Martial Arts discipline?
Have you read the student creed?
Do you agree with our Student Creed?
What is your child's grade point average?
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?
Signature
(in person)
Date
Emergency Contact
Phone #
Email Address
Male
Female
Yes No
Yes No
Yellow pages
Walk-in
Flyers
Special Ads/Other
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
I Acknowledge and Authorize