Karate Programs - INTRODUCTORY FORM

Please complete all parts of this form.  When finished, click Submit.

Date: 

Name: Age:  Ht:  Wt:
DOB:    SSN: 

Address Line 1:
Address Line 2:
City: State:   Zip:

Home Tel:    Work Tel:  Other:  Email: 

Are you planning to move from the above address?   If Yes, when?

Employer:  How long: Position:


COMMITMENT

Have you trained in the Martial Arts before? If Yes, how long:
How long have you been interested in Martial Arts?
Would you like to earn your Black Belt?
If you enroll, will you attend class at least twice per week?

Learning Objectives (Check all that apply.)

Self-defense Self-discipline
Self-confidence Physical Conditioning
Weight Control Recreation
Coordination Other


OTHER ATHLETIC EXPERIENCE / HEALTH HISTORY

Current athletic activities/hobbies:

Previous sports activities:

Do you have any health problems? If Yes, what?


REFERRAL INFORMATION

How did you find out about our school? (Check all that apply.)

Phone Book Coupon in Mail
Saw Sign Staff Member
TV Commercial Newspaper
Present Member Name Other


To Be Completed Upon Intro:

Date:  _________________  
Signature:  _____________________________ 1st Intro Date: __________________
Parent Signature: ________________________  2nd Intro Date: _________________
Intro Payment Received:  __________________ Status: _________________

Thank you!  We will contact you shortly!!!