PCC Student Application

for weekly self-defense classes in pittsburgh

*After your 3-FREE classes, acceptance into a weekly study group requires an application and interview.

Privacy Statement Sexual Abuse & Misconduct Prevention Policy

CONTACT INFO

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile #

(###)

###

####

Email Address

Age

Occupation

Sponsoring PCC Student (if any)

EXPERIENCE/BACKGROUND

1. Have you ever studied martial arts in the past?

2. If so, what did you study? And for how long?

3. How long has it been since you last practiced?

4. If you stopped practicing, why?

5. Do you have any physical or mental challenges? (old injuries, fears, etc.)

STANDARDS/EXPECTATIONS

1. Are you willing and able to make the commitment to attend and participate in weekly classes?

2. Why do you want to study at the Pittsburgh Combat Club?

3. Who would you consider to be your most influential role model? Why?

4. Have you ever been convicted of a felony?

REFERENCES (please list two)

Reference #1

NAME/CONNECTION TO YOU/PHONE#/EMAIL

Reference #2

NAME/CONNECTION TO YOU/PHONE#/EMAIL

TERMS/CERTIFICATIONS

I declare that all statements in this application and any accompanying documents are true and correct, and that any misrepresentations of false statements may be grounds for rejecting my application or, if discovered after my application has been accepted, subject me to the immediate termination of my membership as a student at the discretion of the Pittsburgh Combat Club’s without any reimbursement.

I Agree