Student Registration

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1General

2Adult Details

3Parent / Guardian Details

4Child Details

5Payment Details

Contact Email (used for confirmation emails) *

Dojo Location *

How many adults are you registering? *

How many children are you registering? *

How many training sessions per week will you be attending? *

Please choose what session you will attend. *

Monday
Wednesday
Saturday

Please choose what sessions you will attend. *

Monday & Wednesday (8 yrs & up)
Monday & Saturday (8 yrs & up)
Wednesday & Saturday (8 yrs & up)

Please select below option for all 3 training sessions per week. *

Monday, Wednesday & Saturday (8 yrs & up)

Not registering any adults, therefore this step is not required

Name - Adult 1 *

First

Last

Date of Birth - Adult 1 *

Email Address - Adult 1 *

Mobile - Adult 1 *

Address - Adult 1 *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Name - Adult 2 *

First

Last

Date of Birth - Adult 2 *

Email Address - Adult 2 *

Mobile - Adult 2 *

Same Address as Adult 1

Same Address as Adult 1

Address - Adult 2 *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Name - Adult 3 *

First

Last

Date of Birth - Adult 3 *

Email Address - Adult 3 *

Mobile - Adult 3 *

Same Address as Adult 1

Same Address as Adult 1

Address - Adult 3 *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Not registering any children, therefore this step is not required

Parent Same as Adult 1

Same as Adult 1

Parent / Guardian Name *

First

Last

Parent / Guardian Email *

Parent / Guardian Phone *

Parent / Guardian Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Relationship to child. *

Not registering any children, therefore this step is not required

Name - Child 1 *

First

Last

Date of Birth - Child 1 *

Age of Child 1 at the time of Registration? *

Name - Child 2 *

First

Last

Date of Birth - Child 2 *

Age of Child 2 at the time of Registration? *

Name - Child 3 *

First

Last

Date of Birth - Child 3 *

Age of Child 3 at the time of Registration? *

Name - Child 4 *

First

Last

Date of Birth - Child 4 *

Age of Child 4 at the time of Registration? *

Membership Option (based on number of students) *

Single Student Membership ($40)
2 of more Family Members ($80)

Would you like to purchase a Gi? (Uniform) New Members Please Note: All Junseikan members must wear our a Junseikan Uniform. *

How many Gi's (Uniforms) would you like to purchase? *

Gi Size #1 (Please Measure HEIGHT from head to toe in CM) *

Kids 120cm ($60)
Kids 130cm ($60)
Kids 140cm ($60)
Adults 150cm ($95)
Adults 160cm ($95)
Adults 170cm ($95)
Adults 180cm ($95)

Gi Size #2 (Please Measure HEIGHT from head to toe in CM) *

Kids 120cm ($60)
Kids 130cm ($60)
Kids 140cm ($60)
Adults 150cm ($95)
Adults 160cm ($95)
Adults 170cm ($95)
Adults 180cm ($95)

Gi Size #3 (Please Measure HEIGHT from head to toe in CM) *

Kids 120cm ($60)
Kids 130cm ($60)
Kids 140cm ($60)
Adults 150cm ($95)
Adults 160cm ($95)
Adults 170cm ($95)
Adults 180cm ($95)

Gi Size #4 (Please Measure from HEIGHT head to toe in CM) *

Kids 120cm ($60
Kids 130cm ($60)
Kids 140cm ($60)
Adults 150cm ($95)
Adults 160cm ($95)
Adults 170cm ($95)
Adults 180cm ($95)

The Annual Insurance Payment provides our Instructors and students with Insurance cover in the event that they are injured whilst Training at any of our locations or events held by Nippon-Den Kempo Junseikan Karate club. COST is $30 Per Person.(excl transaction fee) All Members must have current insurance cover to train within the Junseikan Organisation.

Number of Students covered for Insurance Purposes *

I give consent for my / child/ children’s photo to be used in the club Website, any Newspaper or Media used in advertising or promoting the NIPPON-DEN KEMPO GOJU-RYU Karate Club. *

Total Payment Amount *

$0.00

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Card

Name on Card