Application for Training

(Note that this application can be E-mailed directly or printed out and sent through Standard Mail)

(Please Select One)

Martial Arts ___ Cardio___ Boxing___                                                                            Today's Date__________________

Name___________________________________________ Sex________ Age_______ Birth date___________________

Name___________________________________________ Sex________ Age_______ Birth date___________________

Name___________________________________________ Sex________ Age_______ Birth date___________________

Address______________________________________ City______________________ State______ ZIP_____________

Phone (H)_________________________ (W)____________________________ (C)_____________________________

Occupation_________________________________ Parent's Names__________________________________________

Have you previously trained before? Yes___ No___ If yes, what style? __________________________________________

Do you have any medical conditions that the instructor needs to be aware of? Yes____ No____ If Yes, Please explain_______

________________________________________________________________________________________________

How did you hear about us?

___Yellow Pages                ___Print Ad                   ___Radio TV                ___Direct Mail                        ___The Internet

___In House Promo            ___Lead Box                ___Drive By                   ___Word Of Mouth

___Recommended by a friend?  If so, by whom?______________________________________

Choice of Classes ____________________________________ And__________________________________________

Fred Villari's Studios of Self Defense reserves the right to dismiss any student for misconduct or actions which may convey a 

bad image at the Fred Villari' Studios of Self Defense.

I hereby acknowledge that Fred Villari's Studios of Self Defense is not responsible for injury suffered on the premises.  The 

undersigned assumes all the risk inherent and incidental to this type of sports activates as a condition for applying for

admission to this karate studio.

_______________________________________                                   _______________________________________

Signature of Student                                                                             Signature of Parent or Guardian

Mail completed application to:

Villari's Martial Arts Centers

95 Margaret Street

Plattsburgh, NY

12901