Membership Form – New Members Only

Please complete all details. Required fields must be completed in order to submit the form. Please ensure you are familiar with our Code of Conduct prior to submitting this form. If you have any questions about anything on this form please contact us prior to submitting.

Your details:

Family Name:

Given Name(s):

Preferred Name:

Date of Birth: (YYYY-MM-DD)

Street Address:

City:

State:

ZIP:

Contact Phone Number:

Is this a cell/mobile?(required)

Yes

Email:

Emergency Contact:

Name:

Contact Phone Number:

Relationship to You:

Health/Medical Conditions:Please detail any relevant health/medical conditions that may affect your ability to participate in classes/events. You may be required to seek clearance from your doctor prior to commencing class.

Prior Experience with Tai Chi, Qigong, or Other Martial Arts:Please detail any prior experience you have had with Tai Chi, Qigong, or other martial arts.

Demographics:

This information is kept confidential and is only used to help us understand the diversity of our students, and ensure we are providing safe and appropriate services. Please answer any/all you are comfortable with.

Please check any that apply (you may be asked to provide supporting evidence at your first class):

Full-time Student

Retiree

Social Security Beneficiary

If you checked any of the above, please provide additional relevant details. This includes any identifier (eg: Student Number, Grade, Status) and the issuer (eg: social security, school/institution, etc.) Please DO NOT provide your SSN.

Gender:

Preferred Pronouns:

Race:

Ethnicity:

How Did You Hear About Us?

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Membership Form – New Members Only

Your details:

Emergency Contact:

Demographics:

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