Your Name or Parent's Name *

First Name

Last Name

Child's Name

First Name

Last Name

Birthday

MM

DD

YYYY

Goals & Interests *

What benefits would you like to gain from studying the martial arts?

Focus/Concentration

Discipline/Self-Discipline

Confidence/Assertiveness

Fitness

Stress Relief

Self-Control

Fun!

Bully Prevention

Self-Defense/Freedom from Fear

Which program(s) interests you? *

Children's Karate

Adult Karate

Self-Defense Course

Birthday Party

Cell Number or Best Number To Reach You

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###

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Signature *

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