Austin Kenpo Karate CHL Course Application

All fields are required. If an item does not apply to you please enter "N/A" in that field.

Student Information
Name:
Address:	City:	Zip:
Date of Birth:	Age:	Gender:
Email Address:

Emergency Contact/Pick-up Information
(Please list the name of person(s) to contact in the event of emergency)
Name:	Phone:	Relation:
Name:	Phone:	Relation:


(Upon receipt of your application a representative from Austin Kenpo Karate will contact you with further instruction on making your payments)
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I have read and understand the policies set forth in the State of Texas Release of Liability form and agree to the conditions and terms outlined.

Please let us know if you have any additional comments or concerns not otherwise addressed in this application: