Clinic Youth Registration - Palmetto Jujitsu Academy

Child's First Name *

Child's Last Name *

Parent/Legal Guardian First Name *

Parent/Legal Guardian Last Name *

Email *

Phone Number

Address

City

State/Province

Zip/Postal

Country

WAIVER AND RELEASE OF LIABILITY MUST BE SIGNED UPON ARRIVAL

ages 15 and younger

Choose Package *

$60 - 3 day package

$20 - Thursday 5-7 pm

$20 - Friday 5-7 pm

$50 - Saturday 9am-5pm

required

I have one of the following *

Current AJJF Membership

Current ATJA Membership

Current USA Judo Membership

None of the above (event membership $5)

My current Membership # is: *

and it expires: *

I need an event membership

Event Membership $5

How would you like to pay? *

Pay now online through PayPal or Credit Card

Pay full price at the event with cash, check, or credit card

Clinic Total