Leadership Application

Peaceful Warrior Leadership Program Application.

Students 16 and Younger.

Student Name:___________________________________________________________________

Age:_________________ Sex:_______________________ Grade in School:___________

Responsible Parties:

______________________________________________________Relationship_________________

Parents & Responsible Parties Only:

Please review and complete honestly:

Attend all Intramural Tournaments (an average of 2 per year:) and other significant AFSKC or AKANA Events: [ ] Yes [ ] No

Insure attendance in at least 100 classes per year [ ] Yes [ ] No

(An average of 2 classes per week X 50 weeks)

Support your AFSKC school and help expand our student base [ ] Yes [ ] No

Are you willing to support our requirements for “Role Model” Responsibilities in the following areas:

Are you willing to enforce AFSKC Grooming Standards while in a “Leadership Role?” [ ] Yes [ ] No

Are you willing to enforce behavioral standards equal to the leadership role your child will be accepted

into at American Freestyle Karate Club? [ ] Yes [ ] No

Are you willing to enforce healthy behaviors including boycott on underage drinking, smoking and other

drug use? [ ] Yes [ ] No

Are you willing to support our efforts for Excellence in Academics? [ ] Yes [ ] No

Are you willing to support our efforts for personal development through personal leadership and group

leadership training – including written and audio tape support materials? [ ] Yes [ ] No

Commitment and Participation:

Are you willing to insure attendance at 80% or more of Leadership classes?

(Held once per month with the Master’s Leadership Team) [ ] Yes [ ] No

Are you willing to commit to consistent attendance through 2nd Degree Black Belt. [ ] Yes [ ] No

Has your child been diagnosed with any medical condition that would affect their ability to physically

attain mastery in Martial Arts? [ ] Yes [ ] No

If yes – please explain. Attach Separate Sheet if Necessary:

Has your child been diagnosed with any of the following:

ADD or ADHD [ ] Yes [ ] No If yes, medications___________________________

Bi-Polar [ ] Yes [ ] No

Is your child on any Medications? [ ] Yes [ ] No

If yes, What____________________________________________________________

Does your child have any other Emotional or Mental Conditions? [ ] Yes [ ] No

If yes, Please explain – attach separate sheet if necessary.

Is there any history of physical or mental abuse? [ ] Yes [ ] No

If so, please explain – attach separate sheet if necessary

Does your child have any history of disciplinary problems at school? [ ] Yes [ ] No

Has your child ever encountered legal difficulties? [ ] Yes [ ] No

Has your child used any of the following substances:

Alcohol [ ] Yes [ ] No

Illegal Drugs [ ] Yes [ ] No

Inhalants [ ] Yes [ ] No

Cigarettes [ ] Yes [ ] No

If so, Please explain any treatment history.

Please rate your child in the following areas:

Attributes & Abilities Superior Excellent Good Fair Poor Unable to Rate

Home Environment______________________

Contribution to Household________________

Chores_______________________________

“Do it the First Time”____________________

Respectful Behavior____________________

Honesty_____________________________

School:

Achievement in School__________________

Aptitude Academically__________________

Cooperativeness with___________________

Teachers____________________________

Friends and Peers:

Socially Adept_______________________

Honesty____________________________

Please Rate your Family Priorities from the American Freestyle Karate Club Program:

Attributes & Abilities Highest High Low Lowest

Self Defense Capabilities____________

Athletic Achievement______________

Academic Achievement____________

Personal Confidence______________

Character______________________

As a parent or responsible party are you willing to commit to all requirements to insure that your child

achieves Black Belt and Beyond? I respectfully request my child’s consideration for the American Freestyle

Karate Club leadership program. If not accepted for Leadership – I request acceptance into

Black Belt training via Master-Club.

[ ] Yes [ ] No. Signed:___________________________________________________

Signed:___________________________________________________

Student:__________________________________________________

I want to be considered to for Black Belt as a member of the “Leadership Team” and am willing to

commit to consistent training and positive attitude during my training. [ ] Yes [ ] No.

Signed:__________________________________________________________________________

Please attach current school report and any other supporting documentation

(ie. Scout Achievement other awards or recommendations.)

American Freestyle Karate Club Instructor Use Only.

Primary Instructor Evaluating:________________________________________________

Accepted to: [ ] Master Club [ ] Leadership [ ] Staff Training

[ ] Re Evaluation in 2 Months [ ] Rejected

Attributes & Abilities Superior Excellent Good Fair Poor Unable to Rate

Physical Effort in Class_______________________________________________________________

Attitude in Class____________________________________________________________________

Martial Arts Respect_________________________________________________________________

Displayed in Class___________________________________________________________________

Physical Aptitude for Black____________________________________________________________

Belt and Beyond____________________________________________________________________

Maturity Relative to Age______________________________________________________________

Self Motivation_____________________________________________________________________

Participation:

Class 2 + Times Per Week_____________________________________________________________

Intramural Tournaments______________________________________________________________

Seminars or Other Events_____________________________________________________________

External Success:

Achievement in School______________________________________________________________

Behavior at Home__________________________________________________________________

Leadership Exhibited________________________________________________________________

Instructor Commitment:

Are you willing to work with and guarantee that this student will receive at least a 2nd Degree Black Belt

upon completion of all requirements and classroom attendance? [ ] Yes [ ] No [ ] Unsure.

I am willing to work with this student to achieve a high level of “leadership and teaching skills?” [ ] Yes [ ] No [ ] Unsure.

Child’s Commitment:

In your conversations with this applicant has he or she expressed a sincere desire to achieve a Black Belt

and to be a leader and role model in our school? [ ] Yes [ ] No [ ] Unsure

To student and parents.

Please understand that the Leadership Program is highly selective and subject to unanimous approval by –

your school’s Instructor – and, Branch Manager as well as the AFSKC Leadership Council and Finally by

Head Master Instructor Kyoshi McCall.

If your application is not approved for acceptance into the Leadership Program – you may be accepted

into our Master-Club program which is also a path to Black Belt and beyond without the additional

Leadership, Teaching, and Mentorship components of the Leadership Program.

School Use Only:

Approved by Head Instructor? [ ] Yes [ ] No

Approved by School Manager? [ ] Yes [ ] No

If both Yes:

Approved by Master Instructor - Leadership Council? [ ] Yes [ ] No

Approved by Head Master Kyoshi McCall [ ] Yes [ ] No

Final Approval to:

[ ] Reevaluation in the Future: [ ] Next Belt [ ] 6 Months

[ ] Master Club Only.

[ ] Leadership Program Date__________________________

Acknowledged by:

_________________________________________ ___________________________________

Student Parent

Appointment for Follow-Up Conference set for:_____________________________________________

Teacher Recommendation:

Name______________________________________________ is applying to train to Black Belt and

possibly be accepted into a leadership role at American Freestlye Karate Club.

We would appreciate your recommendation and evaluation.

Attributes & Abilities Superior Excellent Good Fair Poor Unable to Rate

Respect for Teachers:_________________________________________

Polite in Class_______________________________________________

Respectful of Rules and Deadlines_______________________________

Respect for Classmates:_______________________________________

Cooperates with Classmates____________________________________

Respectful of Peers___________________________________________

Role Model

Carries self with appropriate____________________________________

respect and consideration_____________________________________

Academic Aptitude

Verbal Skills_______________________________________________

Reading Skills______________________________________________

I personally recommend this student for training in leadership and speaking skills: [ ] Yes [ ] No [ ] Unsure.

I personally recommend this child as a potential role model Martial Artist: [ ] Yes [ ] No [ ] Unsure.

I recommend the parents.

A. I believe that they will effectively support their child’s development [ ] Yes [ ] No [ ] Unsure.

B. I believe that they model appropriate behaviors for their child. [ ] Yes [ ] No [ ] Unsure.

Has the child had any consistent disciplinary problems that you are aware of at school? [ ] Yes [ ] No [ ] Unsure.

If yes, please explain.____________________________________________________________________

Please rate the child on the following:

Attributes & Abilities Superior Excellent Good Fair Poor Unable to Rate

Classroom Participation___________________________________________________

Homework Completion___________________________________________________

Homework Grades_______________________________________________________

Other Assignments______________________________________________________

Grade on Quizzes and Tests________________________________________________

Attendance____________________________________________________________

Personal Responsibility

“No Excuses”__________________________________________________________

“Does it the First Time”__________________________________________________

Any other feedback that we should consider? (feel free to attach separate sheet of paper)

Teacher:________________________________________________________

Signature:________________________________________________________

Phone or Email Address_____________________________________________

School:__________________________________________________________

Grade/Class______________________________________________________

May we contact you if we have additional questions? [ ] Yes [ ] No

You may contact us at:__________________________

Instructor;_______________________________________________________

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