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 Phone (Home) Phone (Alternate) Zip Email School History Pre-school Current School Kindergarten Grade Parental Information Father Occupation Employer Mother Occupation Employer Who initiated child's study of Martial Arts? Parents Child How did you learn about us? Ad Sign Church/Temple Friend Who? Other Learning Objectives (check all that apply) Self-defense Discipline training Coordination Personal training Self-confidence Sports/completition Physical conditioning Weight management/control Art form study Please indicate previous Martial Arts experience (school name, instructor, length of study, etc.) Physical/Emotional Evaluation 1. Does your child take regular medication? Yes No If yes, please specify: 2. Has your child had surgery in the past 2 years? Yes No If yes, please specify: 3. Does your child experience difficulty in any of the following areas? (Check all that apply) Coordination Agility Mental or emotional instability Balance Self-confidence Neurological disorders Endurance Expressing feelings Interacting with other children 4. Does your child have any chronic illnesses? Poor circulation Headaches Asthma Nervous tension Heart condition Back problems Hernia HIV infection or AIDS Arthritis, bursitis Rheumatism High blood pressure Low blood pressure None of the aforementioned 5. Is your child goal/reward oriented? Yes No 7. Has your child ever been attacked or abducted? Yes No 6. Do you experience discipline problems with your child? Yes No I certify the above information is true and correct and give my permission for my child to study under the direction of Master S.H. Yu Martial Arts & Fitness Associates, Inc. Date of First Class Thank you. Please use the space below to share other relevant information that will help us work with your child. Relationship Date
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