Instructors Name__________________________________________

Address:________________________________________

City___________________ State________ Zip Code_________

Telephone_________________________________

Email_______________________@________________

Name of School____________________________________________________________

Martial Arts Taught_________________________________________________________

I hereby make application to participate in the ZIAD Martial Arts assistance program for obesity prevention and disadvantaged at risk youth. I understand it is a sliding scale program and will base my rates to ZIAD referred students on percentage of my charges by a family income scale.

I will cooperate with ZIAD in returning any forms and participating in any surveys for the program..

.A FACIMILE SIGNATURE WILL BE CONSIDERED THE SAME AS AN ORIGINAL.

Signature__________________________________________ Date______________

Please Fax completed form to: 989-672-2483 or e-mail to ibrahamahmed@aol.com

or mail to: ZIAD Healthcare