Private Student Registration

Please complete the following form to register as a private student.

New Private Student Registration

Notify

Class Selection
Your Details
Relevant Conditions/Experience
Discounts and Special Needs

Your Details

Please complete the following details. Your information is kept strictly confidential.

First Name

Last Name

Preferred Name

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone/Mobile

Is the a cell/mobile?

Yes

Emergency Contact

In case of emergency, please provide the details of someone we can contact on your behalf.

First Name

Last Name

Phone/Mobile

Relationship to You

Relevant Health/Medical Conditions

Please provide details of any relevant health/medical conditions which 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, if any.

Special Needs/Considerations

Please list any special needs or considerations you might have in order to attend class. Use the space provided to provide any additional information you feel is important. We will provide advice on how your needs can be met prior to your first class.

Demographic Information

This information is used to help us understand the diversity of our students, and ensure we are providing safe and appropriate services to all. All information is voluntary and kept in strict confidence. Please use your own words/descriptions to answer any/all you are comfortable providing.

Gender

Race

Preferred Pronouns

Ethnicity

Any other demographic information you would like to share? (eg: your identity with any other sociodemographic groups)

How Did You Hear About Us?

I hereby state that I have been provided with, and made myself aware of, Wisconsin Tai Chi Academy's Code of Conduct, and agree to be bound by its conditions while participating in Wisconsin Tai Chi Academy's classes and other events. I understand that failure to do so may restrict my ability to participate in Wisconsin Tai Chi Academy 's classes and other events and may result in cancellation of my membership.

I am:

18 years of age or older, and provide my electronic signature below.

the parent/legal guardian/authorized representative of the student and provide my electronic signature below..

Electronic Signature (type your full name)

Date