*Student's name:
Parent/Guardian:
if under 18 years
*Student's age:
*Student's birthdate:
*Email address:
*Phone number:
Select a Class:
1 Month:
 3 Months:
Junior's:Ages 6-12 years
($155)
($60)
Adult's: Ages 13+years
($75)
 ($190)
There is a $15 one-time-only registration fee for new students.
Fees are due on the first day of classes.
10% Family Discount
Please list other participating family members below.
Note: An online registration form must be submitted for each family member.
Family Members:
*Required Information
Student Information:
www.burgesskarate.com
Martial Arts Classes
Payment of Fees
Cash or cheque is accepted
Cheques should be made out to Mark Burgess