Capital Combat Interview Sheet Capital Combat Canberra by alicejenny

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									Capital Combat Interview Sheet
Date: ………………………………………………………. Gender: Male/ Female
Student Name: ……………………………………………… Date of Birth: …………......................................
Parent/ Guardian: ………………………………………………………………………………………………...
Phone (H): ……………………… ……... (W): …………………………. (M): ……………...........................
Address: ……………………………………………………… Suburb: ………………………………………..
State: …………………………………… Post Code: ………………………………………………………….
eMail: …………………………………………………………………………………………………………….

Occupation: ………………………………………………………………………………………………………
Employed: Y / N Unemployed: Y / N Student: Y / N Uni/TAFE: Y/N Retired: Y / N

1. How did you happen to hear about our school?
Yellow Pages Newspaper Flyer Advertisement Sign               Birthday Party Referral   Website Function

2. Do you live in the area?                       Y/N
   Do you work in the area?                       Y/N
   Do you plan to remain in the area?             Y/N

3. Is there anyone you plan on doing this with    Y/N

4. Is earning a black belt one of your goals      Y/N

5. Are you exercising currently? Y - Activity: …………………………….. N – Last exercised ……………..

    Day you currently exercise(s): M T W T F S S Duration: .…………………………………………….........

6. What days of the week and times are good for you to train/ workout?

    Day(s): M T W T F S S Times: ……………………………………………………………………………..

7. Do you have any previous martial arts experience? Y/N
   If yes what styles? ..…………………………………………………………………………………………...
   How long and what level did you achieve? ………………………………………………………………….

8. If Yes, why did you stop training?
   Likes: ……………………………………………………………………………............................................
   Dislikes: …………………………………………………………………………............................................

9. How long have you been interested in taking up martial arts?

    Not too long     Couple of months      Over a year

10. What encouraged you to take up martial arts?
    Explain: ………………………………………………………………………………………………………
11. Would you like to volunteer for Tournament style events                                   Y/N
    Would you like to volunteer for Amateur style events                                      Y/N
    Would you like to be a Professional Fighter                                               Y/N
    Do you understand the risks involved with Amateur/ Professional fighting                  Y/N

12. Tell us in your own words what type of fighting you would volunteer for and why? ………………………...
    ………………………………………………………………………………………………………………….
    ………………………………………………………………………………………………………………….

13. Do you have Private Health cover?           Y/N
    If yes what level of cover do you have? ..……………………………………………………………………...

13. Please circle all the Mental, Health, Skill, and Physical benefits you think you or your child/ ren could
    improve upon or benefit from by taking up martial arts.

Mental Benefits

Spirit Focus Listening Alertness Discipline Character Motivation Obedience Leadership
Persistence Self Control Self Esteem Goal Setting Self Esteem Goal Setting Self Respect
Better Grades Concentration Determination Achieve Goals Manage Stress Respect for Others

Health Benefits

Cardiovascular Muscle Endurance Muscle Strength            Body Composition

Skill Benefits

Agility Power Speed Balance Coordination Reaction Time

Physical Benefits

Mobility Exercise Flexibility Relaxation Endurance Muscle Tone                 Conditioning Rapid Reflexes
Weight Control Physical Fitness Breathing Control

14. Based on what you have seen so far, what has impressed you the most?
    …………………………………………………………………………………………………………………
    Why?.………………………………………………………………………………………………………….

15. Do you think your family, partner, children would support your decision in getting in to shape and learning
    self defence? Y / N

16. What has prevented you from getting started in a program in the past?
    ………………………………………………………………………………………………………………....
    Is this still a problem? ………………………………………………………………………………………....

17. Please circle any medical conditions that we should be aware of:

Asthma Arthritis Diabetes Knee Problems Back Problems Heart Problems High Blood Pressure
Epilepsy - Please list any other(s): …………………………………………………………………………………
………………………………………………………………………………………………………………………

Note: If you circled any of items above a medical certificate is required clearing you to participate in martial
arts training.
Please list any allergic reactions, physical limitations or special medications or any other medical condition that
we should be aware of:

Allergic Reactions: ………………………………………………………………………………………………..
………………………………………………………………………………………………………………………

Physical Limitations: ……………………………………………………………..................................................
………………………………………………………………………………………................................................

Special Medication: ……………………………………………………………………………………………….
………………………………………………………………………………………………………………………

Other: ……………………………………………………………………………………………………………...
………………………………………………………………………………………………………………………

                                         Membership Condition of Use

I, the undersigned understand the risk of studying Martial Arts and on behalf of myself, my heirs, executors and
administrators I hereby release Capital Combat & all Instructors and all other students of Capital Combat from
any and all liabilities of any nature (including any costs, whether or not the subject of a court order), for any
type of injuries or loss sustained while training, studying, practicing or in the application of Martial Arts. I the
undersigned also state that I am in good physical condition and know of no reason why I cannot study and
participate in Martial Arts or any activities held by Capital Combat.

 I agree to be bound by the rules of Capital Combat.
 I accept the practice of Martial Arts involves the risk of serious injury.
 I understand all fees are non refundable in the event I fail to inform Capital Combat to cease my Direct Debit
(DD) prior to the next DD cycle if for any reason.
 I accept and understand all fees are required in advance of all training undertaken at Capital Combat.
 I accept and understand if fees are not paid for any reason I will be refused access to Capital Combat facilities
and training systems.
 I accept and understand if for any reason funds are not available at the time of the next DD cycle I will be
charged a dishonour fee by the collection agency.
 I accept and understand my training in my chosen systems are arranged by my fees DD and Monthly cash
instalments prior to the month starting or fortnight period and not affected by my lesson schedule/ and or
attendance.
 Capital Combat recommends you seek medical advice before beginning this training or any other exercise
program with Capital Combat.
 Capital Combat recommends that patrons seek and obtain adequate level of Private Health cover to help cover
the undersigned in the event any potential or serious injury suffered requiring specialist medical treatment that
may be sustained during training Martial Arts.
 I agree Capital Combat may take photos and make video and audio material of members classes and school
events, and that these materials may be used for display, promotion and/ or advertising, or sold for profit, and
the member herby waives any compensation to which they may otherwise be entitled for appearing in such
materials.
 Unavailability of Facility or Service – I agree to accept the fact that a particular facility or service in the
premises may be unavailable at any particular time due to a prior booking, mechanical breakdown, fire, act of
God, condemnation, loss of lease, catastrophe, terrorist act, public holidays or any other reason.
 Hours of Operation – Operation hours may vary and subject to change from time to time. This information
and class schedule changes will be notified.
 Lost/ Stolen – Management will not accept responsibility far any equipment that is lost or stolen on the
premises.
 Mobile Phones – For the comfort of all patrons, you are required to please refrain from using mobile phones
whilst in the school/ training facility. Mobiles are to be switched off, turned to silent or stowed with personal
gear in secure lockers within designated change rooms.
 Conduct within the school – Management reserves the right to refuse entry, cancel a membership or request a
member or casual exercise patron to leave the premises if the member(s) does not behave in a responsible
manner, is under the influence of drugs/ alcohol or does not adhere to the conditions of use.

In the event of an emergency, I hereby authorize any licensed medical personnel to perform any accepted
medical procedure deemed necessary and agree to bear the expenses of any such treatment. I HAVE READ
AND UNDERSTOOD AND AGREED TO THE ABOVE AND WOULD LIKE MYSELF AND/OR MY
CHILDREN TO BEGIN LESSONS.

Student Signature: _____________________________________________________ Date: ______________
Note: if you are under the age of 18 years of age, please obtain permission from your parent/guardian by
having them sign this certificate.

Capital Combat Representative: __________________________________________ Date: ______________


Signature of Parent/Guardian:

I ______________________________ on behalf of ________________________________ have read the
Conditions above and agree to abide by them.

Signature of Guardian:_________________________________ Date: ________________________________

								
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