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

Name		Today's Date
Street Address		Home Phone
Address (cont.)		Occupation
City		Work Phone
State/Province		Age
Zip		M/F
Parents Name (if under 18)		E-mail
Emergency Contact		Phone Number

Have You Ever Studied Before?

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?

Hamden

Trumbull