Te Puke Bjj Registration
Please fill out 1 form per student
Student Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Allergies/Medical Conditions
Class Selection
*
Youth Class (10-16yrs) Monday 4pm-5pm
Youth Class (10-16yrs) Wednesday 4pm-5pm
Adults Class (15yrs +) Monday 6:30am-7:30am
Adults Class (15yrs +) Wednesday 6:30am-7:30am
Adults Class (15yrs +) Friday 6:30am-7:30am
Adults Class (15yrs +) Monday 12pm-1pm
Adults Class (15yrs +) Wednesday 12pm-1pm
Adults Class (15yrs +) Friday 12pm-1pm
Adults Class (15yrs +) Monday 6pm-7:30pm
Adults Class (15yrs +) Wednesday 6pm-7:30pm
Payment Type
*
Monthly Direct Debit
Youth Class Invoiced Upfront (Term)
3 Monthly Direct Debit
6 Monthly Direct Debit
Signature
*
Continue
Continue
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