First Name Last Name
Address City State Zip
Phone Sex Please SelectMaleFemale Date of Birth
Employer Address City State Zip
Spouse Name Employer Work Phone
Are you in good health and with no physical problems? Please SelectYesNo
If not, please explain
Do you have any previous experience? Please SelectYesNo
If yes, please describe:
How did you first hear of American Academy of Self Defense? Please SelectYellow PagesWalk-inFlyerSpecial Ad*Referral (Please Specify)*Other (Please Specify)
*Referred by *Other (Please Specify)
Consider the following reasons to learn the Martial Arts and number them in their order of importance to you:
Self Defense Self Confidence Self Control
Self Discipline Physical Fitness Weight Control
Is there any reason you cannot take lessons at an average of twice a week? Please SelectYesNo
If yes, please explain
Have you read the Student Creed? Please SelectYesNo Do you agree with our Student Creed? Please SelectYesNo
What does Black Belt mean to you?
Are you willing to set a goal to develop your mental discipline and physical fitness? Please SelectYesNo
Will you be living in this area for at least one year? Please SelectYesNo
Can you commit to at least 10 minutes DAILY TO PRACTICE AT HOME? Please SelectYesNo
What are your 2 best qualities?
If you are accepted in our program, are you mentally prepared to follow the rules and philosophy of Martial Arts discipline? Please SelectYesNo
The undersigned student 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.
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