AKKA Student Application

AKKA Karate USA
9637 w. 87th st.
Overland Park, KS. 66212
913-385-3518
akkaop@hotmail.com

Member Information

Fill in the information below to join the most exciting and fastest growing club on the Internet.

First Name

Last Name

Address 1

City

State

Postal Code

Phone

Email Address

If student, name of school

Grade

How did you hear about us?

Do you have more family members to register? (if so go to the bottom of this form to add in thier information.

Yes

No

Names of Parents/Guardian

Phone of Parent/Guardian

Father or Husband name

Mother or Wife name

Have you ever studied martial arts before? If so, what style and how long?

I am physically active and participate in athletic activities

Yes

No

Please list other sports/activities you participate in.

All students start with an Introductory Lesson. This is two fold in purpose, first, we want to see what you can or can't do. In other words, how long will it take to reach a point of proficeincy. We also want to see that after you start, that it is something you will like.
The introductory lesson is a one-on-one private lesson which includes a uniform with it. What day and time works best for you? We will call to confirm the time with you.

I am interested in training for (please check all that apply) :

If you've checked 'Other', please explain

Which values do you feel are most important (please check all that apply to you)

What type of program are you most interested in? Please check all that apply to you

If you are accepted as a student, would you set a goal to be a Black Belt?

What does 'Black Belt' mean or signify to you?

For school students, our academic policy for a Brown Belt or higher is a 'B' average or better. If your current GPA is below this, could you bring it up to meet our academic standards?

How do you know when you've been successful at something?

Describe a time at work/school/sports were you felt successful and why that experience was important to you.

Do you currently smoke?

Yes

No

Do you currently smoke?

Yes

No

Do you feel that your current schedule can accomodate karate training

Yes

No

Please tell us the names, ages, and birthdates of all other family members joining.

Accept Liability Agreement: Assumption of Risk: Limitation on Liability

Student and/or Co-signer is aware that certain inherent risks in the participation of this type of physical exercise and training may result in accidents or injury, and Student assumes all risk connected with the participation in the programs provided by AKKA. Student and/or Co-signer represent that the Student is willing, capable, and in good health, and suffers from no physical impairment which would prevent their use of AKKA facilities and instruction. Student and/or Co-signer hereby stipulate that Student has medical approval to proceed with this type of training. Student and/or Co-signer acknowledges that AKKA has not, and will not render any medical services including medical diagnosis of Student’s physical condition. Student and/or Co-signer specifically agrees that AKKA, its officers, employees and agents shall not be liable for any claim, demand, cause of action of any kind whatsoever for, or on account of death, personal injury, property damage, or loss of any kind resulting from or related to Student’s use of the facilities, participation in AKKA programs, exercise or activity within or without AKKA premises, and Student and/or Co-signer agrees to hold AKKA, its officers, employees, and agents, harmless from the same.

I have read and accept the terms and conditions

Yes

No

Indicates Response Required