Name___________________________________________________________________
Address___________________________________________________________________
City_____________________________________________State_________Zip________
Phone______________________Email_______________________________DOB________
Emergency Contact_________________________________________________________

Have you ever studied martial arts before? Y/N _____
If so, in what style(s)? For how long? What Rank did you achieve?
When was the last time you trained actively at a (dojo) school?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Do you have any conditions, injuries or illnesses the instructor(s) should
be aware of? Please note: some workouts can be accommodated for individuals with
serious illnesses to prevent spread of ailments, so please be honest.______
___________________________________________________________________________
____________________________________________________________________________

Signature____________________________________________Date________________

For school use only:

(SR at time of induction)/month__________________________________________