Breese Ki-Do Karate Student Application
Ki-Do Karate is currently accepting new student applications for ages 4 through adult. Please answer all of the questions. Thank you for your interest in Ki-Do!
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Student’s Last Name:
Student’s First Name:
Student's Date Of Birth:
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Phone:
E-mail:
Address:
City, State, Zip:
Please list Martial Arts school(s) attended by the student with duration of training and rank achieved:
Please list other sports or activities that the student is involved in:
What is the PRIMARY benefit are you looking to gain from our program?:
What is the SECONDARY benefit are you looking to gain from our program?:
Does the student have any physical limitations?:
Does the student have any learning disabilities?:
Please provide us with any other information that will aid us in helping the student:
Please provide us with any health concerns/issues that the student has:
Where does the student attend school?:
What level grade is the student?:
Is the student up-to-date on vaccines?:
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Mother's Name:
Mother's Phone:
Mother's E-mail:
Mother's Address (if different than student):
Mother's Employment Status:
Mother's Place of Employment:
Mother's Work Phone (Only used for Emergencies):
Father's Name:
Father's Phone:
Father's E-mail:
Father's Address (if different than student):
Father's Employment Status:
Father's Place of Employment:
Father's Work Phone (Only used for Emergencies):
Student's Parent's Status:
Who has legal custody?:
Who is allowed to watch and/or pick-up student?:
Who is NOT allowed to watch and/or pick-up student?:
Emergency Contact Name 1:
Emergency Contact Phone 1:
Emergency Contact Name 2:
Emergency Contact Phone 2:
How did you hear about Ki-Do Karate, Inc.?
Referral - Who?:
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