Perth Wing Chun Membership Agreement Terms and Conditions - New Students
Please read through this document and complete your information prior to training with Perth Wing Chun.
First Name -- Middle Name -- Last Name *
Your answer
Business name (if applicable)
Your answer
Gender
Birth Date
Your answer
Phone Number (primary) *
Your answer
Phone Number (secondary)
Your answer
Emergency Name and Number *
Your answer
Email address
Your answer
Home Address *
Your answer
Preferred method of contact *
Required
How did you find us?
What attracted you to Perth Wing Chun?
Are you presently exercising? If yes, how many times per week? What kind of exercise is it?
Your answer
What is the main area you (or your child) would like to develop in the coming 3-6 months?
Choose as many that apply to you
What has kept you from starting sooner?
Choose as many that apply to you
I am looking at training *
Have you had any of the following? (Please note: this information will be kept strictly confidential.)
Have you ever had a serious concussion?
Any other injuries or medical conditions we should be aware of? (fractures, dislocations, serious pain, spinal injuries.)
Your answer
To the best of my knowledge, all information contained on this sheet is correct (if under 18 please have parent or legal guardian sign)
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