Signature (in person) |
Self Discipline |
Consider the following reasons to learn the Martial Arts, and number them in their order of importance. |
How did you first hear of American Academy of Self Defence? |
Student ID: |
American Academy of Self Defense KICK-ROBICS Application |
Date: |
First Name: |
Last Name: |
Address & Apt #: |
City, State, & Zip |
Home Phone: |
Gender: |
Date of Birth: |
Age: |
Employer |
Work Phone |
Employer Address: |
City |
Zip |
Spouse's Name: |
Employer |
Work Phone |
Are you 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. |
Date |
Emergency Contact |
Emerg. # |
E-mail Address: |
