Dar-ul-Islah Taekwondo Registration
Dar-ul-Islah boys, girls and adults Taekwondo Program registration. Program runs Sat & Sun from 1:30 pm - 3:00 pm ages 5 years and up.
Primary Member Information
The primary member responsible for students and fees
Member (Parent) - Name *
Your answer
Member - Address *
Your answer
Member - Phone *
Your answer
Member - Email *
Your answer
Member - Relation *
Students Information
Student 1 - Name *
$50 Monthly Fees
Your answer
Student 1 - Birth Date *
MM
/
DD
/
YYYY
Student 1 - Gender *
Student 1 - Email
Your answer
Student 2 - Name
$40 Monthly Fees
Your answer
Student 2 - Birth Date
MM
/
DD
/
YYYY
Student 2 - Gender
Student 2 - Email
Your answer
Student 3 - Name
$30 Monthly Fees
Your answer
Student 3 - Birth Date
MM
/
DD
/
YYYY
Student 3 - Gender
Student 3 - Email
Your answer
Student 4 - Name
$20 Monthly Fees
Your answer
Student 4 - Birth Date
MM
/
DD
/
YYYY
Student 4 - Gender
Student 4 - Email
Your answer
Student 5 - Name
$20 Monthly Fees
Your answer
Student 5 - Birth Date
MM
/
DD
/
YYYY
Student 5 - Gender
Student 5 - Email
Your answer
Emergency Information
List emergency contact information in case we can't reach the primary member
Contact 1 - Name *
Your answer
Contact 1 - Relation *
Contact 1 - Phone *
Your answer
Contact 1 - Email
Your answer
Contact 2 - Name
Your answer
Contact 2 - Relation
Contact 2 - Phone
Your answer
Contact 2 - Email
Your answer
Emergency Release Statement
I the primary member is representing myself or I am the parent or legal guardian of all the students registered and hereby assume full responsibility for the program fees and all the risks of participation in activities associated with this contact Martial Arts class. I do hereby authorize the staff of Dar-ul-Islah to obtain medical aid for registered students from a paramedic unit, ambulance or hospital in case of emergency. *
Required
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