Concord Kung Fu Academy - Official Registration Form

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Registration & Survey

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Study Kung Fu or Tai Chi?

Complete this form for your free introductory lesson.
*Required fields.

First name: Last name: Street address: City (in California): *Zip code:	Telephone: Email: Age: Education:* Employer:

Are you interested in: Kung Fu? Tai Chi? Both? Is this request for you or a relative? Self Relative Relationship? Spouse Child Other relative Name(s): Age(s): Previous martial arts experience? Yes No If YES, what style:* Rank achieved: Years of training:	When do you plan on starting classes? Now! Within 3 months Within 6 to 12 months How did you hear about our site? A popular search engine Link from another site From a friend Event or demonstration Clayton Pioneer Times/Transcript SBC Yellow pages Valley Yellow pages Other If other, what source: *Would you visit this web site again? Yes No

Please list your learning objectives (select all that apply): Physical Fitness Weight Control Stress Management Greater Energy Coordination Flexibility =================== Self Defense Self Confidence Self Control Self Discipline Self Esteem Respect for Others =================== Improve Grades Goal Completion Strength to say "NO" Meet New Friends Competition Recreation How long have you been thinking of getting involved in the martial arts? Recently A few months A few years All my life *Can you attend at least two classes per week? Yes No	Do you have any existing physical conditions or injuries? Yes No If YES, EXPLAIN:* Do you have any physical problems that would prevent you from training regularly? Yes No If YES, EXPLAIN:* Is there anything else that may impact your ability to train? Yes No If YES, EXPLAIN:* How long have you lived in the Concord California area? Less than one year 2 to 5 years 6 to 10 years Over 10 years Will you be in the Concord area for the next year? Yes No

If you have any comments, please add them below: By clicking the "Send" button, you agree to allow us to contact you by mail, telephone and/or email as provided in the information above. The information you provide to us Is only used to contact you at your request. Please review our privacy policy at the link at the bottom of this page.

Note: Some browsers may return a message that states "This is a non-secure form. Do you want to send it anyway?" If you get a message like this, please disregard it and click "send" as the information you provide in this form is encrypted during transmission.

First name: Last name: Street address: City (in California): *Zip code:	Telephone: Email: Age: Education:* Employer:

Are you interested in: Kung Fu? Tai Chi? Both? Is this request for you or a relative? Self Relative Relationship? Spouse Child Other relative Name(s): Age(s): Previous martial arts experience? Yes No If YES, what style:* Rank achieved: Years of training:	When do you plan on starting classes? Now! Within 3 months Within 6 to 12 months How did you hear about our site? A popular search engine Link from another site From a friend Event or demonstration Clayton Pioneer Times/Transcript SBC Yellow pages Valley Yellow pages Other If other, what source: *Would you visit this web site again? Yes No

Please list your learning objectives (select all that apply): Physical Fitness Weight Control Stress Management Greater Energy Coordination Flexibility =================== Self Defense Self Confidence Self Control Self Discipline Self Esteem Respect for Others =================== Improve Grades Goal Completion Strength to say "NO" Meet New Friends Competition Recreation How long have you been thinking of getting involved in the martial arts? Recently A few months A few years All my life *Can you attend at least two classes per week? Yes No	Do you have any existing physical conditions or injuries? Yes No If YES, EXPLAIN:* Do you have any physical problems that would prevent you from training regularly? Yes No If YES, EXPLAIN:* Is there anything else that may impact your ability to train? Yes No If YES, EXPLAIN:* How long have you lived in the Concord California area? Less than one year 2 to 5 years 6 to 10 years Over 10 years Will you be in the Concord area for the next year? Yes No

If you have any comments, please add them below: By clicking the "Send" button, you agree to allow us to contact you by mail, telephone and/or email as provided in the information above. The information you provide to us Is only used to contact you at your request. Please review our privacy policy at the link at the bottom of this page.