Sagake Registration

SAGAKE REGISTRATION

Please complete one form per student.
TERM 4
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Email
example@example.com
Allergies / Medical conditions we need to know about
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Relationship to Student
Payment Option
Current Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Term Start date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Term End Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Weeks remaining
Age Group
J-Kids 3.45-4.30pm
Kids 4.30-5.15pm
Youth 5.30-6.30pm
Adults 7.00-8.30pm
selected number (j-kids & kids)
selected number (youth)
Term Total
Adults classes are not eligible for upfront payment.

Please choose Weekly Direct Debit as your payment option.
Signature
Payment Amount

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SAGAKE REGISTRATION