JIA Club Registration Page

Club Registration Request Form

Fields marked with a star (*) are required.
Create a Password:*
Club Name:*
Instructor First Name:*
Instructor Last Name:*
Club Email:*
Tel 1:*
Club Address 1:*
Club Address 2:
Club City:*
Club State/Prov:*
Postal Code/Zip:
Country Code: *
Region Membership: *
       Date Instructor Started Karate (yyyy-mm-dd):*
       Organization Instructor Started With:*
       Present Instructor Dan Rank:*
       Date Present Rank Acquired (yyyy-mm-dd):*
       Governing Body Registered With (eg. IKTF):*
       Current number of students:*
Date Today (yyyy-mm-dd):*
 
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