Tri City Shokokai Student Registration

Name _______________________________________________

Address _____________________________________________

City/St/Zip __________________________________________

Phone _________________________DOB ________________

Occupation _________________________________________

School __________________________Grade _____________

Previous Training Y/N

Style/Rank _________________________________________

Briefly state why you'd like to take a self defense class

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Applicant Signature _____________________Date ________

Parent/Guardian ____________________________________