ONLINE REGISTRATION – SPECIAL

Name: Samurai Karate
Address: 4/180 Fairbairn Rd, Sunshine West, VIC, VIC 3020, AU
Telephone: 0488818799

Parent Name*
First Last
Select option*
- 1 Student $ 49.00
- 2 Students $ 98.00
- 3 Students $147.00
1st Student Name*
First Last Age
Select a Program 1st Student*
2nd Student Name*
First Last Age
Select a Program 2nd Student*
3rd Student Name*
First Last Age
Select a Program 3rd Student*
Primary Email*
Phone Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Preferred Dojo Location*
Start Date*
DD slash MM slash YYYY
Time Slot Kensington Dojo*
WE run classes Tuesdays and Thursdays only during the month of January
Time Slot Sunshine Dojo*
We run classes on Tuesday and Thursday ONLY during the month of January
Time Slot Waverley Dojo*
Time Slot Samurai Karate QLD Dojo*
Time Slot Caroline Springs Dojo*
How did you hear about us?*
Total
$ 49.00
Credit Card*
Card Details
Cardholder Name

LOCATIONS