* Name: * Last Name:

Address:

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Zip Code: Country:

* Home Phone #: * Work Phone #:

* E-mail:

Dojo: Sensei:

Karate Rank: Kobudo Rank:

Attending Days: May 29 May 30 May 31 June 1

Member Adult Fees: 3~4 Days $165.00 * 1~2 Days $135.00

Member Children Fees:

White~Green Belt: $50.00 * Brown Belt $85.00

Member Pee-Wee Fees: Pee-Wee: $25.00

Non-Member Fees: Additional $25.00

Late Fees: After May 16, 2008 Additional $25.00

Saturday Night Dinner: Number of Persons: at $25 each:

T-Shirts: Quantity: Size: at $18 each:

Total Amount:

Method of Payment: Check by Mail: Credit Card :

Illness/Injuries?

Emergency Contact:

Emergency Contact Phone:

* If you are paying by credit card we will call you to obtain your
information and confirm your registration.