*
Name:
* Last Name:
Address:
City:
State:
Zip Code:
Country:
*
Home Phone #:
* Work Phone #:
*
E-mail:
Dojo:
Sensei:
Karate
Rank:
Kobudo Rank:
Attending
Days: Apr. 29
Apr.
30
May
1
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 Apr. 19,
2016 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.
|