PCC Student Application - Phoenix Survival Program

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

The PCC understands that students in the Phoenix Survival Program are undergoing or have recently underwent changes to their everyday living and working situations. To help give you access to this program, we are willing to work with you and make our training affordable. Please understand that this application is completely private. Your answers here will help us determine how we can best help you get the training you need at the best price for you.

Privacy Statement Sexual Abuse & Misconduct Prevention Policy

CONTACT INFO

Name

First Name

Last Name

Your situation...

(OPTIONAL) Everyone's situation is unique to them. Feel free to give any details about your current situation.

Home Situation

Are you currently living in a woman's shelter or with a relative?

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? If so, what was it and for how long?

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

3. 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