Brockton Karate Club | Forms | Children's Registration Form

Please answer the following questions and then click the "Submit" button located at the end of the form.

Child's Information

Last Name:

First Name:

Age:

Date of Birth: / /

Street Address:

City:

State:

Postal Code:

School:

Grade:

Parent's/Guardian's Information

Last Name:

First Name:

Street Address:

City:

State:

Postal Code:

Home Phone:

Employment Information

Company Name:

Job Description:

How Long:

Work Phone:

Spouse's Information

Last Name:

First Name:

Employment Information

Company Name:

Job Description:

How Long:

Work Phone:

Correspondence Information

Salutation:

First Name:

Last Name:

Street Address:

City:

State:

Postal Code:

Has your child studied Karate before?

If so, how long?

Where?

What style?

Rank obtained?

Instructor's name?

Reason for leaving?

What is your main purpose(s) in having your child study Karate at the Brockton Karate Club?

What attracted you to the Brockton Karate Club?

Sign           Reputation     Yellow Pages   Referral     
Advertisement  Other

If referral, by whom?

If advertisement, where?

If other, explain:

Does your child have any disabilities that may present a problem or hinder his/her progress from studying Karate?

If yes, explain: