Kick-Robics Student Application

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Please fill out this form completely and submit:


    First Name Last Name

    Address City State Zip

    Phone Sex Date of Birth

    Employer Address City State Zip

    Are you in good health and with no physical problems?

    If not, please explain

    Do you have any previous experience?

    If yes, please describe:

    How did you first hear of American Academy of Self Defense?

    *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?

    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.

    Signature (Please Type) Date

    In case of an emergency, call: At

    Your Email (required)

    Cell Phone


    DISCLAIMER: Please View, Print & Sign