Staten Island Jiu Jitsu & Karate Dojo
Online Application For Membership

Please Do Not Complete Application If You Are Not Serious About Becoming A Member.





Home Phone


Work Phone






Date of Birth



Male Female

Present Rank & Style
If None, Enter "None."


3 Character References


Phone Numbers


Prior Martial Arts Experience.

If None, enter "None."




Have You Ever Been Arrested?


If Yes, Offense & Disposition
If No, Enter "None."


How Did You Hear About Us?

Word Of Mouth
Yellow Pages

Referral By Current Member

Was A Prior Member

Internet Website

Please Explain Why You Wish to Study With Us. What Do You Hope To Gain In Your Training? 
And Any Reason(s) For Potential Acceptance.

I understand that during the course of instruction, Instructors of the Goshindo Kempo Karate & Samurai Jiu Jitsu Assoc.; S.I. Jiu Jitsu & Karate Dojo and/or other members or authorized persons will be engaged in a course of conduct requiring physical contact; and I give full consent to such contact as is required by the training. The undersigned agrees the Assoc.; Dojo, its agents, members and employees, shall not be responsible for accidents or injuries of any kind, whether the same shall be caused by or attributable to their negligence or the negligence of any of them or otherwise.

The undersigned shall indemnify and same harmless the Assoc.; Dojo, its agents and employees, against all damage, loss or expense which they or any of them incur as a result of any claim or action which may at any time be made or instituted on behalf of the above named member including, without being limited to, any claim or action based upon the negligence of the Assoc.; Dojo, its agents, members or employees.

I, the undersigned, have completed this application truthfully. I understand that if, upon review of this application, it is revealed that I have made any false statements, my membership will be terminated without delay or refund. Submission of this application does not guarantee enrollment. The Goshindo Kempo Karate & Samurai Jiu Jitsu Assoc; S.I. Jiu Jitsu & Karate Dojo reserves the right to accept or decline applicants.

Copyright 2002 Goshindo Kempo Karate & Samurai Jiu Jitsu Assoc. All rights reserved.
Revised: May 18, 2006