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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:
Juniors
(under 14):
$35.00
Adult Fees:
$55.00
Non-Member
Fees:
$75.00
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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