Greenwich Kenpo Karate

  

Registration Form

Information Sheet
Name:
Address:
Email:
Phone:
Home: Work:
Occupation:
Emergency Contact:
Phone: Relationship:

Karate
How do you hear about Greenwich Kenpo Karate? Yellow Pages   Flyer   Newspaper   Continuing Ed   Web Site

Friend   Other - Specify: 

Have you studied a Martial Art Before?
If so, when? What style?
Where?                              
Rank Obtained?                 
Any other athletics  interest?

General Information
Age:

Any physical problem or difficulties we need to be aware of?

Family Information: Single   Married      Children
Education: High School   College   Advance College
Other Interest (hobbies, etc):
Goals & Objectives - Please check all that apply:    Self Defense     Physical Fitness   Greater Energy  Endurance

    Flexibility          Recreation          Self Esteem        Self Confident

    Self Discipline         Stress Management    Increased Strength

    Meet new people    Other 

Any question please contact Jeff Khan, Chief Instructor, at jeffskahn@sbcglobal.net or at (203) 834-2626