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* Home Phone #: * Work Phone #:

* E-mail:

Dojo: Sensei:

Karate Rank: Kobudo Rank:

Attending Days: Nov. 14 Nov. 15

Member Adults Fees: Adults $135.00

Member Children Fees:

Brown~Green Belt: $65.00 * Yellow~White Belt $45.00

Member Pee-Wee Fees: Pee-Wee: $20.00

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:

Contact Phone:

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