Phone Welcome! Please complete this questionnaire to help us learn more about you and your motivation in studying Martial Arts. This will assist us in designing a rewarding training program for you. Thank you. Date of Application Date of Birth Student Name Address City State Email Employeer How did you learn about us? Ad Sign Church/Temple Friend Who? Other Learning Objectives (check all that apply) Self-defense Personal training Physical conditioning Self-discipline Self-confidence Weight management/control Sports/completion Art form study Phone (Work) Phone (Home) Phone (Cell) Zip Education/Degree Completed Civil status Single Married Do you have children? Yes No Please indicate previous Martial Arts experience (school name, instructor, length of study, etc.) Medical Data relevant to studying Martial Arts 1. Do you take regular medication? Yes No If yes, please specify: 2. Have you had surgery in the past 2 years? 3. Do you have any chronic illnesses? (Check all that apply) Poor circulation Back problems Ulcers High blood pressure Headaches Sinusitis Heart condition Low blood pressure Asthma Lack of energy Arthritis, bursitis None of the aforementioned Nervous tension Hernia HIV infection or AIDS 4. Have you ever been involved in a fight? Yes No 6. Do you have a criminal record? Yes No 5. Have you ever been attacked or abducted? Yes No 7. Are you in the habit of attaining a desired goal? Yes No Thank you. Please share any other relevant information you may believe is necessary.