Karate Registration
Please note that all fields are required.

Name:

Age:

Address:



City/State:      Zip:

Home Phone:

Cell Phone:

E-mail:

Emergency Contact:

Relation to applicant:

Emergency Contact phone:

Emergency Contact
alternate phone:




Tuition of $100 per student, or $50 for new students, is due on site (1414 S. Weller) by the first class, October 6.