Please provide the following contact information: (for new students only)


Today's Date

Street Address

Home Phone

Address (cont.)



Work Phone



Zip M/F
Parents Name (if under 18) E-mail

Emergency Contact

Phone Number



Have You Ever Studied Before?

Yes No  Rank: Style: When:


What are your interests: (check all that apply)

Self-Defense          Self-Confidence       Aerobic Conditioning  Weight Loss         
Stress Management     Self-Control          Self-Discipline       Respect             
Other (specify)                

List any special physical or mental problems that might need special attention by the instructor.

How Did You Hear About The Studio?

Phone Call

Newspaper Promo Event Radio
Yellow Pages Friend Drive By Other
Walk In Lead Box TV     

Adults Only
Do you have a Police Record?    Yes    No

  The Academy of Kempo Martial Arts reserves the right to dismiss any student, at any time, for misconduct of actions which may convey   a bad image to this Academy of Kempo.

  I hereby acknowledge that the Academy of Kempo Martial Arts is not responsible for any injury suffered on the premise. The undersign assumes all the risk and incidental to this type of sports activities as a condition for applying for admission to this Karate Studio.

I hereby acknowledge that the about statements are true. Accept    Decline


Which Studio is closest for you?