Robert Jones EAST WEST INTERNATIONAL BLACK BELT ACADEMY

                                                                                             Application for Admission

 Student NameSexAgeBirth Date

Responsible Party Name

 Address    City     Zip Code 

Telephone Height    WeightMarital Status

Employer  Occupation  Telephone#  

School (if for child)   Grade Level  Teacher

 

Physical Fitness Self Control Self Esteem
Coordination Strength to say "NO" Competition
Improve Grades Greater Energy Flexibility
Weight Control Self Discipline Respect for Others
Self Confidence Meet New Friends Recreation
Stress Management Self Defense  

  How did you come to our website? Have you ever studied before?

  If yes, Which Art? How Long?Rank Obtained

How long have you wanted to study the martial arts?

How long have you lived in the area?            Can you attend two classes per week?  Yes  No

Will you be living in the area for the next year?   Yes  No

Student or his Parents acknowledges the existence of the potential for personal injury in participating in a course of instruction in an a course of instruction in an activity such as Wu Shen Pai Kenpo and that he or she, in consideration of being admitted to East West International Black Belt Academy, is assuming this risk without liability to this school or its instructors, assigns, employees, etc. by executing this agreement and participating in this course of instruction