Membership Application

PeopleSafe Online Membership Application
Adult Members Only

#time# #date#

Membership Type

#MembershipType#

 
Personal Information
First Name #Fname#
Last Name #Lname#
Address #Street#<
#City#, #State# #Zip#
Home Phone No. #HomePhone#
Email Address #EmailAddress#
Date of Birth #BirthDate#
Sex #Sex#
Occupation #Occupation#
Work Phone No. #WorkPhone#
Emergency Contact #EmergencyContact#
Phone #EmergencyPhone#

Character Reference 1 #CharacterReference1#
Phone #CharacterReferencePhone1#
Character Reference 2 #CharacterReference2#
Phone #CharacterReferencePhone2#
Do you have any physical or emotional impairments? #EmotionalPhysicalProblems#
If yes, describe #EmotionalPhysicalProblemsDescribed#
Have you ever been charged or convicted of a felony? #Felony#
If yes, offense & disposition #FelonyDescribed#
Are you on any medications? #Medications#
If yes, describe #MedicationsType#
  
Martial Arts Experience
Last Dojo you belonged to #Dojo#
Instructor #Instructor#
Style Rank When School
#Style1# #Rank1# #Date1# #Dojo1#
#Style2# #Rank2# #Date2# #Dojo2#
#Style3# #Rank3# #Date3# #Dojo3#
#Style4# #Rank4# #Date4# #Dojo4#
Please explain why you 
selected to study at our dojo.

#WhyStudyWithUs#

How did you hear about us?

#HowHear#

 

#Certification#   

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