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 Martial Arts Scholarship: Online Application Form

** The deadline of the submission is on July 31st, 2013.
Should you have any questions about the grants, please contact us ».

APPLICANT INFORMATION

Please fill our the applicant's information below
* required information
Title:
First Name: *
Middle Name:
Last Name: *
Gender: *
 Male 
 Female 
Email Address: *
Phone Number *

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Date of Birth *

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Address Line 1: *
Address Line 2:
City: *
State: *
Country: *
Zip Code: *
Your Website: (if any)
How did you hear about us?: *

EDUCATION:

Name and Address of School: *
Degree/Diploma: *
Graduation Date: *

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Skills and Qualifications:
(if any)

MARTIAL ARTS HISTORY:

(Please skip the fields if you have never studied martial arts)
Year you begun training:
List of all martial arts SCHOOLS and the YEAR you have attended in the past and present:

*Separate by comma ( , ) if more than one
List of all martial arts INSTRUCTORS you have studied under in the past and present:

*Separate by comma ( , ) if more than one
List of all martial arts STYLES you have studied under in the past and present:

*Separate by comma ( , ) if more than one
School Website: (If any)

APPLICANT'S BACKGROUND:

Please tell us about yourself: *
Please tell us why you are applying for the scholarship and how it helps you: *
Please tell us why you deserve to receive the scholarship: *
Please tell us what martial arts mean to you: *
Please tell us your goals and dreams: *

APPLICANT'S BACKGROUND:

Martial Arts school's name you wish to study at: *
Instructor's name you wish to study under: *
School's website:
Phone Number: *

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Email Address:

REFERENCE:

Please provide us the name and contact information of your reference:
1) Full Name: *
1) Phone Number *

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I certify that information contained in this application is true and complete. I understand that false information may be grounds for not granting me or for immediate cancellation of scholarship at any point in the future if I am granted. I authorize the verification of any or all information listed above. I recognize the risks of injury that are common to any performing arts program that my child or I participate in and I do hereby waive and release the Shin Koyamada Foundation from and against any and all claims, actions, causes of action, damages, costs, liabilities, expense of judgments, including attorney's fees and court costs, that arise out of my participation in this program. I hereby execute this form permitting my minor child and / or myself to participate in the Shin Koyamada Foundation's program.

Do you agree with the terms and conditions? *
 Yes, I agree. 
PREPARED BY: *
TITLE: *
INITIALS: *
DATE: *

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