Aikido Eastside Kids Special Registration

Aikido Eastside Kids Special Registration
KIDS INFORMATION
Student Full Name

First NameLast Name
Age Group

all ages - 5 pm - 6 pm
PARENT/GUARDIAN CONTACT
Parent Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Phone Number

Area CodePhone Number
OTHER CONTACT INFORMATION
Name, Phone, Etc.
Name, Phone, Etc.
TWO WEEK TRIAL INFORMATION
When would you like to start?

MonthDayYear
Payment
prevnext( X )
Kids 2 Week Trial$24.95
REFERRAL INFORMATION

Please share with us information on how you found us.
Referral

Friend or ColleagueGoogleYahooBingOther
Should be Empty: