Inquiry Form
We need your first & last name and at least one phone number to contact you.
Your Last Name:
Your First Name:
Telephone:
Daytime:
Evening:
Please contact me at my:
Day Phone
Evening Phone
Best time to call is:
The above is all we need to contact you. However, the remaining items will help us respond to you more efficiently.
I am inquiring on behalf of:
Myself
Child/Children
Someone Else
If
Child/Children
:
First Child's Name:
Child's Age:
School Grade:
Child's Gender:
Male
Female
Second Child's Name:
Child's Age:
School Grade:
Child's Gender:
Male
Female
If
Someone Else
, what is the other person's name?
Last Name:
First Name:
Which programs interest you? (Check all that apply.)
Adult Karate
Self-Defense at Thousand Waves
Youth/Teen Karate (third grade and older)
Self-Defense at My Worksite
Junior Karate (first and second graders)
Empowerment Stories in Action
Little Kicks Karate (ages 4 yr to kindergrdn)
Making Peace: Meditations on Activation
What goals do you wish to achieve? (Check all that apply.)
Improve fitness
Develop self-confidence
Feel safer
Learn non-violent conflict resolution skills
Experience mind / body / spirit unity
Learn more about meditation and philosophy
Do you have previous martial arts training?
Yes
No
If Yes,
What style?
For how long?
Rank earned?
How long ago?
How did you hear about Thousand Waves? (Check all that apply.)
Saw the store front.
Saw this website
Saw an advertisement in (publication name):
Attended seminar led by Thousand Waves teachers.
A Friend; What is their name?
Other. Please describe:
Other information you need or would like to provide:
Your Address:
Street Address:
Apt/Unit#:
City:
State:
Zip:
Your Email:
I would like to receive occasional communications from Thousand Waves
by USMail, and/or
by Email.
I do not wish to receive communications from Thousand Waves
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