Membership Application & Questionnaire
Mother’s Name ______Father’s Name______
Address______City______Zip______
Home Phone______Mobile Phone______
Student’s Name(s)______
Date of Birth ______Age______
Email______
Please answer the following Questions Honestly:
Do you feel that our program will be a positive experience for your child?
Yes ( ) No ( )
When did you first become interested in getting your child into our program? ______
Do you value educational programs for your child/children?
Yes ( ) No ( )
Are you a Single Parent?
Yes ( ) No ( )
Are you interested in your child/children having fun while learning?
Yes ( ) No ( )
Whose idea was our martial-arts program?
Yours ( ) Child ( ) Both ( )
Can your child benefit from getting regular exercise?
Yes ( ) No ( )
Please Turn Over
Our program requires your involvement in order for your child/children to be successful, do you consider yourself/selves involved parents?
Yes ( ) No ( )
Are you willing to dedicate yourself to your child’s success by being aware of your child’s progress?
Yes ( ) No ( )
In which ways would you like your child benefit from our program?
( ) Increased Confidence ( ) Better Focus ( ) Improved Self-Esteem
( ) Athletic Ability ( ) Self-Defense ( ) Respect-self/others
( ) Discipline- doing more on their own ( ) Self Motivation
( ) Self-Control ( ) Social Skills ( ) Fun ( ) Fitness
( ) Concentration ( ) Balance ( ) Goal-Setting
( ) Leadership ability ( ) Self-Belief ( ) Better Grades
Can you invest one to three hours per week to help your child attain your desired results?
Yes ( ) No ( )
Are you willing to have patience in getting the results you want?
Yes ( ) No ( )
Has your child expressed an interest in martial-arts in the past?
Yes ( ) No ( )
Do you support your child’s positive interests? Yes ( ) No ( )
Are you willing to only render positive feedback to your child about their progress?
Yes ( ) No ( )
Do you encourage your child to set future goals for themselves?
Yes ( ) No ( )
Do you encourage your child to follow through on goals they set for themselves?
Yes ( ) No ( )
Who else (if anyone) will be involved with transportation and/or tuition?
______
What is most important to you and your child at this time?
______
Membership Application & Questionnaire, Adult Program
Name ______
Address______City______Zip______
Home Phone______Mobile Phone______
Date of Birth ______Age______
Email______
Please answer the following Questions Honestly:
Have you ever done martial arts in the past?
Yes ( ) No ( )
Are you currently exercising regularly?
Yes ( ) No ( )
If Yes, what are you doing?
______
If No, when was the last time you were physically active?
______
When did you first become interested our program?
______
What has stopped you from starting martial arts in the past?
Yes ( ) No ( )
What is your marital status?
Single ( ) Married ( )
Please Turn Over
Our program requires that you do at least two classes per week, can you fit that in ?
Yes ( ) No ( )
Off the top of you head which days of the week and times are best?
______
In which ways would you like to benefit from our program?
( ) Increased Confidence ( ) Better Focus ( ) Fighting Skills
( ) Athletic Ability ( ) Self-Defense
( ) Discipline- ( ) Self Motivation ( ) Speed
( ) Fun ( ) Fitness ( ) Flexibility ( ) Power
( ) Concentration ( ) Balance ( ) Flexibility
Are you willing to have patience in getting the results you want?
Yes ( ) No ( )
Will you be in the area for at least one year?
Yes ( ) No ( )
What is most important to you at this time?
______