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:
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.
In case of emergency, call
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
CONGRATULATIONS ON YOUR DECISION TO TAKE THE FIRST STEP NOT ONLY IN
BECOMING A BLACK BELT, BUT TO BE SUCCESSFUL IN EVERYTHING YOU DO!
Is there any reason you cannot take lessons at an average of twice per week?
If yes, please explain:
Have you read the student creed?
Do you agree with our Student Creed?
What does a Black Belt mean to you?
Are you willing to set a goal to develop your mental discipline and physical fitness?
Will you be living in this area for at least one year?
Can you commit to at least 15 minutes a week to practice at home?
In your opinion, what are your 2 best qualities?
If you are accepted into our program, are you mentally prepared
to follow the rules and philosophy of Martial Arts discipline?
Adult Student Application
at
Date
Email Address
Male
Female
Yes No
Yes No
Yellow pages
Walk-in
Flyers
Special Ads/Other
I Acknowledge and Authorize
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No