Student Application Student Application First Name * Last Name * Age * Parent's Name/s (If student is a minor) Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Student / Occupation * Email * Name of School Attended For 18 Yrs. and Younger Cell Phone * Alternative Phone What Benefits Are You Most Interested In Obtaining By Participating/Training In Our Program? Self Defense Weight Control & Fitness Confidence Flexibility Endurance Self Discipline Perseverance Focus & Concentration Courtesy & Respect How Did You Hear About Us? * Email Passing by Studio Another Student Social Media Website OtherOther Any Previous Martial Arts Training? * Yes No Style: Rank: Where Studied: Health Condition: Please list any physical defects, illnesses or conditions (such as asthma, epilepsy, high blood pressure, ADD, ADHD, autism, etc. I agree there are NO physical conditions or illnesses which would render the applicant unable to participate in a strenuous physical activity, such as martial arts training. Physical Condition Agreement & Acknowledgment * Recognizing that the nature of this activity involves risk of personal injury, and with this knowledge, the applicant agrees to indemnify and hold harmless Encinitas Karate, Inc. and it's officers, instructors and staff from any and all liability and losses whatsoever arising from participation in this program. Risk of Personal Injury Waiver * Student Signature * Clear Date * Guardian Signature * Clear Date * If you are human, leave this field blank. Submit
