Student Name

Parent's Name (if Student Under 18)

Email Address

Style Style TaeKwonDoAikidoPentjak SilatTai Chi Chuan

Date of Birth

Address

City

Province

Email

Phone

How Did You Hear About Soengkono World Class Martial Arts?

How Often Do You Excercise? How Often Do You Excercise?Prefer Not To SayLess than 3 times per week3 to 5 times per week

Do you have any medical restrictions that could affect your exercise program? Do you have any medical restrictions that could affect your exercise program? YesNo

Describe any medical restrictions you may have.

Which goals are the most important for you (or your child) to achieve? Check all that apply Which goals are the most important for you (or your child) to achieve? Check all that apply Fitness Lose Weight Self-Defense Body and spirit Improve Academic Performance Bullying Solutions / Intervention Tournament Fighting Reduce Stress Improve Behavior / Character Education Weapons Training & Defense Improve Focus / Self-Discipline Improve Confidence Professional (Police, Security, etc) Other

Describe Other Goals You May Have

Have you ever studied Martial Arts? Have you ever studied Martial Arts?YesNo

If so, describe what style it was, your level and/or the time you trained in it: