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PARK'S MARTIAL ARTS
SCHOOL OF SELF DEFENSE
662 SE Jackson St, Roseburg, OR 97470 | 541.580.9862
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Registration Form
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Student's First name
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Student's Last name
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Email
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Date of Birth
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Phone Number
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Street Address
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City
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State
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Postal Code
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Emergency Contact
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Phone Number
Choose Desired Program:
Kids Program
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What got you interested in joining our program?
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How did you here about us?
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Are there any medical conditions that we should be aware of?
List any previous martial arts and/or self defense experience.
For Tuition Evaluation, please check all that apply to you.
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Park's Martial Arts Registration
Wednesday Nights
662 SE Jackson St., Roseburg, OR 97470
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