NICC Taekwondo Registration Form
5001 Wilcox Road Dublin, Ohio, 43016
Phone : (614) 527-7777
Contact : Anam Udddin
Email :
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Note: The Fee is $50 per month (1 months) per student. In addition to this fee, there will be a fee for the Uniform and belt promotion test which is once in 2 or 3 months depends on the progress of the student.
Student First Name *
Student Last Name *
Student Date of Birth *
Father First Name *
Father Last Name *
Father Cell Phone *
Home Phone
Father Email *
Mother First Name *
Mother Last Name *
Mother Cell Phone *
Home Phone
Mother Email
Home Address (Street, City, State, Zip) *
Emergency Contact Name (Other than Parents) *
Emergency Contact Phone (Other than Parents) *
I agree to the following liability waiver *
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I agree to the following liability waiver: *
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