Form

Welcome To Kokikai Aikido Boston, Inc!

Form Instructions: To Sign Up for the Beginner's Course or Regular Adult Membership please fill out the form. If you are requesting information only Required Fields (orange *) are necessary. Please place any comments in comment box at bottom of the form. If you are unable to complete this form please feel free to contact us at info@kokikaiboston.com or 617/910-4700.
Personal Information
First Name *
Last Name *
Birth Date
Gender
Aikido Specific Information
Main Interest
Previous Martial Arts Experience (not required!)
Program Type *
Aikido Kokikai Rank
Contact Information
Address
City
State
Zip

E- Mail Address *
Daytime Phone *
Evening Phone
Medical and Emergency Information
Do you have any allergies, physical limitations, or medical conditions of which the dojo should be aware with regard to your safety while training or the safety of others? *
If yes describe condition briefly
Emergency Contact Name
Emergency Contact Phone
Uniform Ordering Information
Height
Body Size (for uniform ordering)
Dates and Times
Available Days	Monday 7:30-9:00 Tuesday 6:00-7:30 Wednesday 6:00-7:30 Thursday 7:30-9:00 Saturday
Course Start Date
Comments
Comments
Payments
Click a payment option (If paying by check, mailing instructions will be given to you upon receipt of this form.) *	Pay with Credit Card or PayPal (check an option below) Mail Check or Money Order to dojo Bring payment to first class (check or cash) Information only, no payment now
If you would like to pay through Pay Pal please click an option below. If you are not paying at this time, click Submit and you are done.
Pay with VISA, MC, AMEX, eCheck or Pay Pal	Beginner Course - Six Weeks Includes Uniform! ($150) Pre-Payment Beginner's Course ($50) Adult Monthly Fee ($50) Adult Quarterly Fee ($150.00) Adult Semi-annual Fee ($250.00) Adult Annual Fee ($500.00) Total :

Problems or questions about this form? Please contact us at info@KokikaiBoston.com or 617/910-4700.