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Date:
Student ID:
First Name:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Sex:
Date of Birth:
Age:
Employer Address:
City:
State:
Zip:
Work Phone:
Spouse:
Work Phone:
Are you in good health and with no physical problems?
If not, please explain:
Previous Experience:
If yes, 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:
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:
Date:
In case of an emergency, call:
At:
*Home E-mail:
Work E-mail:
WELCOME TO
Kick-Robics Student Application
CLICK ON THE SEND BUTTON TO TRANSMIT YOUR APPLICATION TO SIFU RICK
American Academy of Self Defense
I, _____________________, have chosen to participate in the American Academy of Self Defense program of Kick-Robics. I hereby waive any claim I may have at any time against American Academy of Self Defense.
Regarding any personal injury or damage I may suffer or incur by such participation, I have been advised that participation in American Academy of Self Defense's Martial Arts and exercise program may result in: abnormal blood pressure, fainting, disorders of the heartbeat, rare iinstances of heart attack, broken bones, and muscle tearing. I hereby accept these risks.
To my knowledge, I do not have any limiting phtsical condition or disability that would preclude my participation in American Academy of Self Defense's Martial Arts & exercise program and further, certify that I have fully and accurately completed all forms submitted to me by American Academy of Self Defense intended to disclose any such limiting physical condition or disability.
I also understand that a physician's examination should be obtained by all participants prior to involvement in the Exercise/Martial Arts program. If the participant refuses to obtain a physicians permission, he/she must sign the following statement:
I,_____________________, have been informed that it is advisable for me to obtain a physician's approval for participation in a progressive exercise/Martial Arts program. I fully understand the strenuous nature of this program. I accept the complete responsibility for my health and well being in the voluntary Exercise/Martial Arts program and related testing. I understand that no responsibility is assumed by American Academy of Self Defense or the leaders of the exercise/Martial Arts program.
_________________________________ ________________
Signature Date
3345 Kimber Drive - Newbury Park, CA 91320 (805) 499-1799
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