SPRING 2005 SELF DEFENSE WORKSHOPS
Registration form

Please print and complete this form and send it with a check (payable to JMCA) or cc number to:
Kaleidoscope Program | Julia Morgan Center for the Arts | 2640 College Ave. | Berkeley, CA 94704

Student name: _______________________________________________________ Male/Female?______________

Date of Birth: __________________________

Parent/Guardian Name (if applicable):_______________________________________________________________

Address:____________________________________________________________________________________________

City: ______________________________________________State: ______________Zip: ________________________

Day Phone: _____________________________________ Evening Phone: ___________________________________

Fax: ___________________________________________________________

Email: _______________________________________________________________________________

Enrolling in:

Class Title	Fee
Self Defense for Women	$75	$__________
Self Defense for Daughters/Parents	$75	$__________
Self Defense for Sons/Parents	$75	$__________
(Self-defense fees include one child+one caregiver - addtl’ family members $10 each, up to 2 addtl’ participants)
Total Class Fees:		$
Registration Fee (due once each calendar year)		$25
Credit Card Fee (if app.)		$12
Kaleidoscope Scholarship Donation (opt.)		$5
TOTAL ENCLOSED:		$__________

Credit Card: VISA  /  Mastercard       

Name on Credit Card: ___________________________________________________________

Authorized Signature: ___________________________________________________________

Credit Card #: ____________________________________________________________________

Exp: ________________