REGISTRATION: VICTORIA JUDO CLUB

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Last Name:           First Name and Initials:

Address:   City:  

Province:     Postal Code:

Home Phone # :      Cell # :     Work Phone # :

Email Address:

Date of Birth (Day, Month, Year)?     Gender? Female    Male

Current Rank (Belt Color):     White Yellow Orange Green Blue Brown Shodan Nidan Sandan Yondan Godan Above Godan     If Black Belt, Judo Canada #: 

Date of last grading (e.g., Sept  2005):

Weight:  kilograms

NOTE: With which martial arts group are you affiliated (interested in):    Judo Aikido Kung Fu

In case of emergency, name of person we can contact:

Number at which that person can be reached: