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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: Sep. 14
Sep.
15
Sep.
16
Member
Fees:
Adults $295.00
Children $175.00
(*)
Families w/ more than 1 child $135.00
Ea
Non-Member
Fees: Additional
$50.00
Late
Fees: After
Aug. 31,
2012 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.
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