Course Registration Form

Student Registration Form

Fill out the form carefully for registration
Student Name

First NameMiddle NameLast Name
After School Program (pick up from School) (Ages 5-13)Kids Aikido evening Class (Ages 7-12)Adult and Teen age Aikido ClassIaido (adult only)Summer Camp 2023 (Ages 4-14)Homeschoolers Morning Class (Ages 3-6)Homeschoolers Morning Class (Ages 7-12)Kids Aikido evening Class (Ages 3-6)Women Self Defense Class
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Full Name
Grade
School Name
Emergency Contact Phone number
Relationship
Signature

Clear
Appointment
Date

MonthDayYear
Date
Parent/Guardian
Full Name
Parent/Guardian
Full Name
Secondary Parent/Guardian
First and Last Name
Relationship
Student E-mail
example@example.com
Mobile Number
Format: (000) 000-0000.
Phone Number
Format: (000) 000-0000.
Work Number
Format: (000) 000-0000.
Additional Comments
Email
example@example.com
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Student Registration Form