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Enrolment Form   |   Discipline Code
Enrolment Form
Name

Date of Birth
Address
Contact Phone
Email
Occupation
Period of Enrolment:                    Summer Term          Autumn Term          Winter Term          Spring Term
Q1. Please circle the most appropriate response to the statements that follow:
I'm learning martial arts…
Strongly
Disagree
Disagree
Don't Know
Agree
Strongly Agree
For Its Physical Benefits (health, fitness, strength, etc.)
1
2
3
4
5
For Its Mental Benefits (confidence, concentration, etc.)
1
2
3
4
5
For Its Social Benefits (fun, friendship, etc.)
1
2
3
4
5
For Its Life Benefits (strategy, philosophy, etc.)
1
2
3
4
5
For Physical Self-Defence Skills
1
2
3
4
5
For Stick & Blade Weaponry Skills
1
2
3
4
5
For Tournament Competition Skills
1
2
3
4
5
Q2. How did you hear about our classes?
Q3. Do you have any medical condition, need for prescribed medication, or recurring injury that the Instructor should know about because it could be aggravated by or during martial arts training or competition?
o
Internet Web Page / Email
o
Brochure
o
Flyer / Poster
o
Demonstration
o
Newspaper / Magazine Article
o
No
o
Newspaper / Magazine Advertisement
o
Yes (Please List):
o
Instructional Video
o
Instructional Book
o
Yellow Pages
o

 Referral from:
Name of Emergency Contact Person
Emergency Contact
Phone Number
o
 Other:
Q4. Do you have any previous martial arts experience?
o
 No
o
 Yes (Please Specify):
Martial Art
Period Of Study
Grade Attained
Instructor or Club
DECLARATION:
I hereby swear that all statements made above are true and correct. I have received a copy of the Discipline Code which I have read and agree to abide by. I understand that the Instructors of the Combat Kungfu Academy reserve the right to dismiss any student/s for misconduct or actions that convey a bad image. I hereby acknowledge that I train at my own risk, and declare that the Combat Kungfu Academy, its Instructors, Members and Agents, are not responsible for any injuries to person or damages to property suffered before, during or after classes. I understand that fees are subject to change without notice, and are non-transferable (to another person or period) and will not be refunded for any reason, including failure to attend classes. I understand that for health and safety reasons, all students are expected to have their own uniform, focus mitt, boxing gloves, shin & instep pads, mouthguard, and weaponry, maintained in good working order as a condition of continued membership.
Applicant / Parent or Guardian
Witness
Date
Club Location