Online Inquiry Form

We need your first & last name and at least one phone number to contact you.

Your Last Name:
Your First Name
Phone: Day:     Eve:
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 Name:     Age:     Male Female
  School Grade:
Second Child Name:     Age: Male Female
  School Grade:
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:
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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