Monthly membership Form

Monthly membership form

(in person classes)
Full Name*

PrefixFirst NameLast Name
Child's Name

First NameLast Name
Date of birth

MonthDayYear
Date
Child's date of birth

MonthDayYear
Date
Multiple Children
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Emergency Contact
Name and Number
Medical Conditions / Injuries
How did you hear about us?
Start Date*

MonthDayYear
Date
Signature*

Clear

Monthly membership$345.00

(Urban Jitsu for both adults and children includes a $60 registration, $60 uniform, and first month membership of $225)

Select membershipQuantity
Item subtotal:$0.00

Total $0.00

Credit Card

Should be Empty: