Shaolin Martial Arts Center

2631C Bridgeway Sausalito, CA 94965( 415.331.8838 6 415.331.8878

Application for  Tai Chi r     Kung Fu r     Chi Kung r   

 

Name: __________________________________________________________________________________    Male r      Female r

               Last                                                First                                                                                 M.I.

Address:________________________________ City _________________ State _______  Zip ___________     Single r     Married r

Phone: (Home) ____________________ (Cell) ____________________ E-Mail ___________________@______________________

Birth date: _____________________________  Birthplace ____________________________________  

Education: __________________________________________   Social Security#_________/_______/__________    

Employer: ________________________________ Occupation __________________________ Phone ________________________ 

Employer address:_____________________________________________________________________________________________

Martial Arts Background:   Style __________________________    Rank ________________________

Years of Training ______      Instructor _______________________    Location _____________________

Referral:   Friend r    Yellow Pages r      Web Site r      Other: ________________________________

Learning Objectives

q       Physical Fitness

q       Coordination

q       Improve Grades

q       Weight Control

q       Self Confidence

q       Goal Completion

q       Stress Management

q       Self Control

q       Strength to say “NO”

q       Greater Energy

q       Self Discipline

q       Meet New Friends

q       Self Defense

q       Self Esteem

q       Competition

q       Flexibility

q       Respect for Others

q       Recreation

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 Are there any existing physical conditions such as brittle bones, weakened or damaged joints, torn muscles or any condition which can lead to being easily injured?   r  YES    r  NO   If YES, Explain: _____________________________ (use reverse for more space)

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 Do you have any physical problems that would prevent you from training regularly? r  YES    r  NO  If YES Explain:__________

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Is there anything else that may impact your ability to train? r YES    r  NO   If YES Explain:_____________________________

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Do you smoke?   r  YES    r  NO   If YES how many packs per day.__________________

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Do you drink alcohol?  r  YES    r  NO   If YES how much per day.__________________

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How long have you been living in the area? ______________________________________

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How long have you been thinking of getting involved in a Martial Art? _________________

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Can you attend at least two classes per week?  r  YES    r  NO 

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Will you be in the area for the next year?   r  YES    r  NO

I, the undersigned, do hereby voluntarily submit my application for admission to The Shaolin Martial Arts Center for attendance and participation in lessons at Shaolin Martial Arts Center.  Furthermore, I do hereby assume full responsibility for any and all damages, injuries, or losses that I may sustain or incur, if any, while participating in any activity at or for Shaolin Martial Arts Center.  Furthermore, I do hereby waive all claims against the instructors and/or fellow students of said classes, and the owner of the building, for any injuries which I may sustain in the course of activities at or for Shaolin Martial Arts Center Furthermore, I voluntarily consent that any picture furnished by me or any pictures taken of me in connection with Shaolin Martial Arts Center may be used for publicity and/or promotion of same. Furthermore, I waive the right to any compensation in regard thereto.  I understand that there are NO REFUNDS for any fees or tuition paid by me for the classes at Shaolin Martial Arts Center, unless the classes or courses in which I am involved are discontinued. I also realize that I am responsible for payment in a regular and timely manner.

Signature of Applicant______________________________________________________ Date: __________________

If applicant is under eighteen years of age, this release and consent must be signed by a parent or legal guardian.

Signature of Parent/Guardian:________________________________________________ Date: ___________________