Application to Train

Here is a questionaire we now forward to prospective students. Because of what we teach, we have decided it is best to know who we are inviting to train with us. In some circumstances answers can be a simple “yes” or “no”..or “N/A”…there are no incorrect answers as long as they are truthful. You can expound on a topic as much as you care to or keep it very concise. There is no rush to have it done immediately. This also helps us understand what the “student to be” hopes to learn and what expectations or concerns he or she might have, as well as priorities of interest, since silat is a very comprehensive art. If you have further questions feel free to contact me. Once completed E Mail this to

APPLICATION TO TRAIN : Pencak Silat Dallas / Bela Diri Dallas

1. Full Name :

2. Date of Birth / current age :

3. Phone Number(s) :

4. Current Address :

5. Preferred E mail Address :

6. Current Occupation :

7. Previous Military / Law Enforcement Experience :

8. Previous EMS/ Emergency Responder Experience :

9. Highest Level of Education :

10. Foreign Languages Spoken :

11. Past Criminal History :

12. Marital / Family Status :

13. Do you currently participate in any fitness or athletic activities?

14. Have you any previous or current experience in a Martial Arts Program, Self Defense Program , Hand to Hand Combat Training or Weapons training ?? Fencing, Boxing or Wrestling? Please elaborate: (years trained, instructor, style , rank achieved, currently or no longertraining, military source, etc ). Do you have any Instructor Rankings?

15. Have you trained in any style of Pencak Silat or Kuntao before? Again, please elaborate.

16. Why are you seeking training in Pencak Silat versus any other available martial art or self defense program?

17. What aspect of Pencak Silat most appeals to you or interests you the most?

18. What aspects of our Core Curriculum is most interesting to you? Areyou seeking training in one specific silat program or are you wanting to train in all of them?

19. What are your specific goals ? ( self defense, fitness, spiritual development, traditional Asian culture and art,would like to eventually teach, etc.??)

20.How would you assess your current level of health and fitness? Do you have any special limitations or impairments that we might need to work around or accommodate?

21. How would you rate your temperment, level of patience and ability to work with others?

22. Please provide us with 3 character references( Professional ,personal , training associates, teachers) with contact information.




23. Our training provides material that can be mastered in a very short period , as well as material that takes the investment of time and energy ,coupled with regular practice. Do you feel that you can commit toregular training with our group?

24. Pencak Silat/ Silek/ Maen po do not reveal their underlying logic,theory , complete application or secrets immediately. Do you feel you have the patience to train though the material long enough for the art to begin to reveal those things to you?

25. Are you able to work with others patiently, use appropriate force and exercise good self control so that training is safe and that we areall able to help each other improve?

26. Do you understand that all martial art and self defense training carries with it an intrinsic risk of injury ? Do you accept this and agree that you shall exercise the best possible level of self control ,ego control and “restrained enthusiasm” , so that you will minimize the chances of injuring your partner(s) or yourself ??

27. Are there any special considerations or conditions that might maketraining with us difficult? Any special issues that we might need to work around?

28. Please elaborate on any special things that you feel we should know about you….previous experiences ( good or bad) ….special concerns…..feelings about the martial arts …….curiosities……..etc.

29. What would you feel are your greatest strengths?

30. What do you feel are your greatest weaknesses?

31. Do you have a general religious affiliation?

32. Have you had any significant world travel, especially to Indonesia ,Malaysia or the Phillippines?

33. Do you have a current Martial Art or Self Defense teacher? If so,do they mind your training with us?

34. Do you believe you can “empty your cup” and enter into training withan open mind and a williness to learn what we offer ??(understanding that we do not require you to reject what you have already learned from either other teachers or life experience)

35. What positive things do you believe you can bring into the group?? How do you feel your presence and participation could add to our common goals of self improvement and growth in Pencak Silat??

With Respect ,
Doc Dority
Pencak Silat Dallas