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First Name Last Name
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Are you in good health and with no physical problems? Please SelectYesNo
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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
Will you be living in this area for at least one year? Please SelectYesNo
The undersigned student/parent/guardian 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 such treatment.
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