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*
Name:
* Last Name:
Address:
City:
State:
Zip Code:
Country:
*
Home Phone #:
* Work Phone #:
*
E-mail:
Dojo:
Sensei:
Karate
Rank:
Kobudo Rank:
Attending
Days: November 15
November 16
Member
Adult Fees:
Adults,
Jr. Black Belt &
Brown Belt
$135.00
Member
Children Fees: White~Green
Belt: $65.00
Member
Pee-Wee Fees: Pee-Wee:
$20.00
Non-Member
Fees: Additional
$25.00
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.
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