Enrollment Form

Member Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent/Guardian’s Name (responsible party if member is under 18 years of age)

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

How did you hear about Family Karate Center?

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Facebook Page

Friend

Other

Are you connected to the Family Karate Center Facebook page? *

Yes

No

Do you have health problems we should know about? *

Yes

No

Have you participated in any self-defense or martial arts training before? *

Yes

No

I have read and agree to the Rights and Responsibility and Financial Agreement and Risk Agreement (below) *

Yes