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.
