Student application.

 

Full legal name.___________________________________________________________

Name to be used in class.___________________________________________________

Address_________________________________________________________________________________________________________________________________________________________________________________________________________________

DOB__________________   Gender.  male   female  n/a  other_____________________

Phone______________________________ Cell ________________________________

Email __________________________________________________________________

Educational level_________________________________________________________

Parent/Guardian__________________________________________________________

Phone______________________________ Cell ________________________________

Email __________________________________________________________________

 

Physical illnesses, medical conditions or challenges that may require accommodation ________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Learning challenges _______________________________________________________

________________________________________________________________________________________________________________________________________________

 

Medications _____________________________________________________________ ________________________________________________________________________________________________________________________________________________

 

Emergency contact name ___________________________________________________

Phone_____________________________ Cell _________________________________

Physician__________________________ Phone ________________________________

 

Previous martial arts experience, training and rankings. ___________________________

________________________________________________________________________

________________________________________________________________________________________________________________________________________________

 

Student Signature________________________________________ Date____________

 

Instructor Signature_______________________________________ Date____________

 

Guardian Signature_______________________________________ Date____________

 

Note that this form is kept confidential and no information is published or given out. This form also serves as and emergency form and a copy of it may be given to emergency medical personnel. 

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