Sagake Registration

SAGAKE REGISTRATION

Please complete one form per student.
TERM 3
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Date of Birth

DayMonthYear
Date
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
Class Selection
Current Date

MonthDayYear
Date
Term Start Date

MonthDayYear
Date
Term End Date

MonthDayYear
Date
Weeks Remaining
Total term cost
Adults classes are not eligible for upfront payment.

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

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NZDDescription
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SAGAKE REGISTRATION