Shaolin Kung-fu Tai Chi Martial Arts in Phoenix and Tempe, Arizona

New Shao-Lin Student - WHITE BELT

Returning CSC Student

Current Student - Information Update Only

Transferring CSC Student from CSC

Chinese Shao-Lin Kung Fu Phoenix, Arizona
FOR OFFICE USE ONLY Instructor/Assistant Initials
Registration Fee
	Tai Chi	Regular
1 Year Paid in Full
6 Months Paid in Full
3 Months Paid in Full
Month to Month

Date (mm/dd/yyyy)

* First Name

* Last Name

* Street Address

* City

* State

* Zip Code

* Home Phone

Work Phone

* Birth Date (mm/dd/yyyy)

Occupation

* Email Address

* Emergency Contact

* Emergency Phone

If current or returning Shao-Lin student:

Level

Date originally started Shao-Lin Art

Drive-By	Flier or Brochure	Google Ad	Current CSC Student	Friend/Family
Dance FX Studios	Surfing the Web	Yahoo! Ad	Previous CSC Student

Other

Health and Fitness	Weight Loss	Martial Arts	Self-Discipline	Philosophy
Conditioning	Stress Relief	Self-Defense	History	Chinese Culture

Other

* Indicates Response Required