June 2009 Black Belt Grading Registration Form

This form is to be completed by registrants who intend on paying on-line through PayPal™ only. If you want to pay by cash or check, download the registration form, then fill it in and hand it into the sensei with the money
The parent or guardian, in the case of under age students, are expected to complete this form and by doing so, have agreed to the conditions and releases outlined in this document.
All registrations must be completed and fees paid by June 1, 2009 .
Register and pay on-line using PayPal™. To use this service you must have a PayPal™ account. The sign-up is simple enough and secure. (see PayPal info) Once the account has been set up, select the SEND MONEY tab on the webpage then enter account@blackbelt-institute.com for the account to send to. The rest is very easy

Last Name:
First Name:
Age:
Phone Number:
Present Belt Level:
Email Address:
School or Instructor's Name
Medical Information Please supply information regarding medications, recent injuries and or surgeries. Also indicate if you wear a Medic Alert Please Note: This information is for use by our first aid team and will be destroyed after the grading

In case of an emergency, I give permission for my child to receive medical treatment. In case of such an emergency, please contact:

Parent or Guardians Name:

Parent/Guardian's Phone#: