KENAKI KARATE ASSOCIATION, LLC
Student Enrollment & EFT Form
Afterschool - School
Grade
Day School
Grade
Karate
Mighty Rangers
Junior
Adult
Base
Black Belt
Summer Camp
Participant 1
Name
DOB & Age
Participant 2
Name
DOB & Age
Medical/Medications Taking Currently:
List Any Medical Issues or Allergies:
Medical Notes:
Mother, Father or Guardian 1
Mother, Father or Guardian 2
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Place of Employment
Work Number
EMERGENCY INFORMATION 1
Name:
Relationship
Phone
EMERGENCY INFORMATION 2
Name:
Relationship
Phone
Signature
Continue
Continue
Should be Empty: