Highland Ki-Do Karate Student Application
Please fill out as completely as possible.
Student’s Last Name:
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Student’s First Name:
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Student's Date Of Birth:
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Phone:
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E-mail:
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Address:
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City, State, Zip:
Please list Martial Arts school(s) attended by the student with duration of training:
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Please list Martial Art rank achieved by student, such as belt color:
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Please list other sports or activities that the student is involved in:
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What specific benefits are you looking to gain from our program?:
Please provide us with any other information (health concerns, learning needs, etc.) that will aid us in helping the student:
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Is the student up-to-date on vaccines?:
Mother's Name:
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Mother's Phone:
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Mother's E-mail:
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Father's Name:
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Father's Phone:
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Father's E-mail:
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Emergency Contact Name 1:
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Emergency Contact Phone 1:
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Emergency Contact Name 2:
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Emergency Contact Phone 2:
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How did you hear about Ki-Do Karate, Inc.?
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Referral - Who?:
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