Shaolin Martial Arts Center

2631C Bridgeway ∙ Sausalito, CA 94965 ∙ ( 415.331.8838 ∙ 6 415.331.8878

Application for: Tai Chi r Kung Fu r Chi Kung r

Name: __________________________________________________________________________________ Male r Female r

Last First M.I.

Address:________________________________ City _________________ State _______ Zip ___________ Single r Married r

Phone: (Home) ____________________ (Cell) ____________________ E-Mail ___________________@______________________

Birth date: _____________________________ Birthplace ____________________________________

Education: __________________________________________ Social Security#_________/_______/__________

Employer: ________________________________ Occupation __________________________ Phone ________________________

Employer address:_____________________________________________________________________________________________

Martial Arts Background: Style __________________________ Rank ________________________

Years of Training ______ Instructor _______________________ Location _____________________

Referral: Friend r Yellow Pages r Web Site r Other: ________________________________

Learning Objectives

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

	Are there any existing physical conditions such as brittle bones, weakened or damaged joints, torn muscles or any condition which can lead to being easily injured? r YES r NO If YES, Explain: _____________________________ (use reverse for more space)
	Do you have any physical problems that would prevent you from training regularly? r YES r NO If YES Explain:__________
	Is there anything else that may impact your ability to train? r YES r NO If YES Explain:_____________________________
	Do you smoke? r YES r NO If YES how many packs per day.__________________
	Do you drink alcohol? r YES r NO If YES how much per day.__________________
	How long have you been living in the area? ______________________________________
	How long have you been thinking of getting involved in a Martial Art? _________________
	Can you attend at least two classes per week? r YES r NO
	Will you be in the area for the next year? r YES r NO

I, the undersigned, do hereby voluntarily submit my application for admission to The Shaolin Martial Arts Center for attendance and participation in lessons at Shaolin Martial Arts Center. Furthermore, I do hereby assume full responsibility for any and all damages, injuries, or losses that I may sustain or incur, if any, while participating in any activity at or for Shaolin Martial Arts Center. Furthermore, I do hereby waive all claims against the instructors and/or fellow students of said classes, and the owner of the building, for any injuries which I may sustain in the course of activities at or for Shaolin Martial Arts Center. Furthermore, I voluntarily consent that any picture furnished by me or any pictures taken of me in connection with Shaolin Martial Arts Center may be used for publicity and/or promotion of same. Furthermore, I waive the right to any compensation in regard thereto. I understand that there are NO REFUNDS for any fees or tuition paid by me for the classes at Shaolin Martial Arts Center, unless the classes or courses in which I am involved are discontinued. I also realize that I am responsible for payment in a regular and timely manner.

Signature of Applicant______________________________________________________ Date: __________________

If applicant is under eighteen years of age, this release and consent must be signed by a parent or legal guardian.

Signature of Parent/Guardian:________________________________________________ Date: ___________________