Learn Kempo Karate and Gracie Jiu-Jitsu

Online Registration

You may register for group Self Defense classes on-line using this form or by completing a paper form available at our Dojo. By using our on-line option you are registering for group classes that are offered at $150 per month. With paid monthly membership you are able to attend all appropriate classes at our training facility. Classes are offered Monday - Saturday at different times depending on your program, student age and skill level.

Payments can be made using our on-line payment option below.

Please note that all payments are non-refundable.

Registration Form

Student Name:

Student's Age:

Student's DOB

Parent Name (if under 18)

Physical Address:

Email:

Phone:

OK to Text?

Any relevant medial conditions:

Emergency Contact Name:

Emergency Contact Phone:

Relationship to Student:

Is it OK to photograph student during class for marketing purposes?

Date you wish to start

Training Facility

If Student is under 18 yoa: I/We, the under signed parent(s) or guardian(s) of all students listed above, do hereby give permission for my/our child (children) to participate in programs at Clark's Self Defense. I/We recognize that martial arts is a rigorous sport and there are inherent risks involved. On behalf of my/our child (children) and on my/our own behalf, I/we agree not to sue and to forever waive all claims against Clark's Self Defense and its owners, stuff, and instructors of and from any and all liability, loss, damages, costs, medical expenses, long term care, or emotional distress arising out of any personal injury, including total disability, paralysis, and death, which may occur to any of my/our children while on the premises of or under the instruction, supervision, or control of Clark's Self Defense. I/we hereby testify to my/our child's (children's) sound health of mind and body and I/we authorize Clark's Self Defense to seek medical treatment at the nearest medical facility in case of emergency.

If Student is 18yoa or older: I, do recognize that martial arts is a rigorous sport and there are inherent risks involved. On my own behalf, I agree not to sue and to forever waive all claims against Clark's Self Defense and its owners, stuff, and instructors of and from any and all liability, loss, damages, costs, medical expenses, long term care, or emotional distress arising out of any personal injury, including total disability, paralysis, and death, which may happen to me while on the premises of or under the instruction, supervision, or control of Clark's Self Defense. I hereby testify to my own sound health of mind and body and I authorize Clark's Self Defense to seek medical treatment at the nearest medical facility in case of emergency.