KENUKAN ACADEMY
Online Application Form
Please Fill Out The Information Below So That A Counselor Can Discuss Your Best Program Options
(*Required Field)
Applicant's Legal Name
*
First Name
Last Name
Applicant's Nickname (If Applicable)
Parent's Name (If Minor)
First Name
Last Name
Applicant's Age
*
Applicant's Birthdate
*
-
Month
-
Day
Year
Date
Applicant's Gender
*
Please Select
Male
Female
N/A
Legal Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Mobile Number
Format: (000) 000-0000.
Phone Number
Format: (000) 000-0000.
School / Employer
Additional Comments
How Were You Referred To Kenukan Academy?
*
Coach
Doctor
TV
Social Media
Present Member
Teacher
Web Search
Other
Program Questions
1. Previous Experience?
*
Yes
No
If So, What Art / Style / Years?
2. Please Check All Areas of Study That Interest You:
*
Ju-Jitsu / Judo (Grappling)
Karate / Kickboxing (Striking)
Self-Defense
Mixed Martial Arts (MMA)
Weapons
Competition
3. Which Proficiency Level Do You Wish To Obtain?
*
Basic
Intermediate (Green)
Advanced (Brown)
Expert (Black)
4. How Long Do You Plan To Train?
*
Less Than 1 Year
1-2 Years
2-3 Years
3+ Years
5. Are You Interested In Having Flexible Class Days & Times?
*
Yes
No
6. Please Select All Additional Training Benefits That Interest You:
*
Increased Flexibility
Increased Endurance
Self-Discipline
Self-Confidence
Self-Esteem
Focus / Concentration
Submit
Kenukan Academy
220 West Cedar St. • Olathe, KS • 66061 • 913.782.5425 • www.kenukan.com
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