Individual Application, Promotion or Renewal (Web)

SEISHIN RYU MARTIAL ARTS ASSOCIATION

*Print out and send to address below - E-Mail:  soshu@seishinryu.com   for fees

P.O. Box 514 Cedar Falls, Iowa 50613 (319) 266-5923

INDIVIDUAL REGISTRATION

FULL NAME:

ADDRESS:                                                                         CITY:

STATE:                                       ZIP:                              PHONE: (       )

MALE /FEMALE:              DATE OF BIRTH:        /       /           HEIGHT:            WEIGHT:

PRESENT MA SCHOOL:

CURRENT BELT COLOR:                               CURRENT KYU OR DAN RANK:

STARTING DATE (at white belt - if not explain):

PRESENT STYLE:                                                         DATE OF LAST PROMOTION:

PRESENT SENSEI:                                                        HIS/HER PRESENT RANK:

                                                                       APPLICANTS

Type or print on the back of this form a complete outline of your Martial Arts history giving: DATE, DOJO, SENSEI, HIS/HER RANK, STYLE, YOUR RANK.

Attach copies of documents to support this outline. On a separate sheet of paper list all kata you perform and note the Sensei from whom you obtained each kata.

S.R.M.A.A. SCHOOL NUMBER: **                       S.R.M.A.A. MEMBERSHIP NO.: **
**Issued by SRMAA
                                                             FOR PROMOTION ONLY

DATE OF PROMOTION:         /      /       NEW BELT COLOR:                KYU/DAN RANK:

PRIOR RANK:                                         PREVIOUS PROMOTION DATE:          /         /         

PRIOR STYLE:                                               PRESENT STYLE:

SENSEI:Sign                            DATE:               STUDENT:Sign                            DATE:

SRMAA Indiv Reg Form001

Print out form and send to the above addrees E-Mail:  soshu@seishinryu.com  for Fees.