JKI Membership Information Form

Jikishin-Kai International

Individual Membership Application
Applicant Category:*

Active (currently training in budo)Supporting/Sustaining (not actively training in budo)
Name: *

Prefix (Dr., Rev., etc.)First NameMiddle Name or InitialLast NameSuffix (Sr., Jr., PhD., etc.)
Street Address:*

Street Address

Street Address Line 2

CityState / Province / County / Prefecture / Etc.

Postal / Zip CodeCountry
Mailing Address (if different):

Mailing Address

Mailing Address Line 2

CityState / Province / County / Prefecture / Etc.

Postal / Zip CodeCountry
Preferred Phone Number:*

Country CodeArea CodePhone Number
Alternate Phone Number (if any):

Country CodeArea CodePhone Number
Email Address:*
example@example.com
Date of Birth*

MonthDayYear
Date
Gender:*

MaleFemale
Forms of Budo Currently Practiced:*

Karate-doRyukyu / Okinawa KobudoIaido / Iaijutsu / Batto-ho / Batto-doJodo / JojutsuKenjutsu (Koryu)Kendo (Sport)AikidoJudoJujutsu / Aiki-jujutsuOther (list below)
Other Forms of Budo Currently Practiced:
List here, separated by commas
Rank Currently Held in Shito-Ryu Karate-do*
Name of Organisation Awarding the Rank Listed Above:*
Name of Organisation (enter "N/A" if no rank held)
Rank Currently Held in Okinawa Kobujutsu*
(Bo, sai, tonfa, kama, nunchaku, eku, etc.)
Name of Organisation Awarding the Rank Listed Above:*
Name of Organisation (enter "N/A" if no rank held)
Rank Currently Held in Muso Jikiden Eishin-Ryu Iaijutsu:*
Name of Organisation Awarding the Rank Listed Above:*
Name of Organisation (enter "N/A" if no rank held)
Rank Currently Held in Shindo Muso-Ryu Jojutsu:*
Name of Organisation Awarding the Rank Listed Above:*
Name of Organisation (enter "N/A" if no rank held)
Rank Currently Held in Ono-Ha Itto-Ryu Kenjutsu:*
Name of Organisation Awarding the Rank Listed Above:*
Name of Organisation (enter "N/A" if no rank held)
Highest Rank Currently Held in a non-JKI Art:
Name of the Style of the Rank Listed Above:
(Kyokushin, Wado-Ryu, JKD, Judo, BJJ, etc.)
Name of Organisation Awarding the Rank Listed Above:
Name of Organisation (enter "N/A" if no rank held)
Highest Awarded Budo Title Currently Held:*
Name of Organisation Awarding the Title Listed Above:*
Name of Organisation (enter "N/A" if no rank held)
Informal Title Used:
Other Informal Title Used:
Enter title above, if "Other" was selected from drop-down menu. Otherwise leave blank
Name of Your Current Dojo:*
Dojo Name (if not currently training, enter "None" or "N/A")
Address of Your Current Dojo:*

Street Address (if not currently training, enter "N/A" in all fields

Street Address Line 2

CityState / Province / County / Prefecture / Etc.

Postal / Zip CodeCountry
Phone Number of Your Current Dojo:

Country CodeArea CodePhone Number
Email Address of Your Current Dojo:
example@example.com
Name of Your Current Sensei:*

First NameLast Name
What is Your Current Role at the Above Dojo?*
Which of the Above Information Can We List on Our Membership Roster?*

NONEMy NameMy Street AddressMy Mailing AddressMy Email AddressMy Personal Phone NumberMy Budo RankMy Awarded Budo TitleMy Informal TitleName of My Current DojoAddress of My Current DojoPhone Number of My Current DojoEmail Address of My Current DojoMy Role at My Current Dojo
My Products
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Annual Individual Membership DuesIndividual membership dues for calendar year 2023
$25.00

Charter Membership Discount25% discount for Charter Membership available only if annual dues are paid in full by 31 March 2023
$-5.00

Total

$0.00
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Jikishin-Kai International