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Wah Lum Consultation Intake Form
Please answer the questions in order to assist us with continuing to provide a safe training environment. We respect your privacy. By filling out this form you agree to observe distancing from others and abide to onsite safety
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Email
*
Your email
Which classes are you interested in?
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Adult Kung Fu
Tai Chi
Kids Kung Fu (9-12)
Little Mantis Kung Fu (5-8)
Fitness/Personal Training
Required
Has anyone planning to visit the Temple for the consultation recently been infected with covid19 or been in contact with anyone who has tested positive for covid19 within the past 2 weeks?
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Yes
No
Does anyone planning to visit the Temple have any symptoms of a virus or illness? (such as but not limited to: fever, coughing, shortness of breath, fatigue, muscle soreness, sore throat, runny nose, nausea, etc.)
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Yes
No
Covid19 Protocols
Vaccination is not required to train at the temple. We do however ask for your vaccination status and preferences for classes that may include contact, as everyone has varied levels of comfort.
Have you received the covid19 vaccine?
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Yes
I do not plan to get the vaccine.
Not yet, but I plan to get my first or second dose within the next month.
For KIDS/LM class: Has your child received the covid19 vaccine?
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Yes
No
Not yet, but I plan to get my first or second dose when it is available to me or within the next month.
N/A - I do not have a child who wants to sign up for kung fu
The following section is in regards to your comfort levels while training.
I am comfortable engaging in physical contact for technique correctives and application movements with instructors.
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Yes
No
I am comfortable engaging in physical contact for technique correctives and application movements with other students (regardless of vaccination status).
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Yes
No
Other:
By typing my full name below, I agree this acts as my official signature.
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