Outreach Programs for America's Youth...

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Self-Defense Home Page! See You at Class!

Self-Defense Registration Info

Please fill out the information below and push the
"Create My Form!" button.

Student Information

Student's Last Name:
Student's First Name:
Age:
School Attends:
New CY Student: Returning CY Student:
If Returning Student: Belt Color:
If Returning Student: Degree: 1st  2nd  3rd

Parent or Guardian Information

Parent's Last Name:
Parent's First Name:
 
Street:
City:
State:   Zip:
 
Home Phone: ()
Work Phone: ()
E-Mail:

How do you plan on paying class fees?
Save $1.00 per class if pre-pay!
Registration fee: $5.00
(Note: No payment is required at this time.)

I would like to pre-pay and save $1.00 per class:

I would like to pay weekly:

Uniforms and recommended safety equipment.

Attention Returning Students Only
Uniforms, hand and foot pads are mandatory equipment for all
Pre-Yellow Belts and higher ranked students!
Purple belts and higher must have chest gear for sparring and should attend all tournaments!


Uniforms are highly recommended for all new students.   Each   comes with pants, jacket and a white belt.  They are loose fitting, highly durable and specifally designed for practicing the techniques that students will learn in class.
Our uniforms are black with the world famous "Champion Youth USA" logo!
Cost is a very reasonable $29.00.
Shirt Size Uniform
Size
Child Small 0
Child Medium 1
Child Large 2
Adult Small 3
Adult Medium 4
Adult Large 5
Adult X-Large 6
I plan on purchasing my uniform at class:
No thank you, I already have my uniform!
Hand and Foot Pads are worn for protection during training equipment drills and while practicing with partners.  They are mandatory for all advanced students and highly recommended for our new students as well.
Cost is $22.00 per set of hand pads and $22.00 per set of foot pads.

Hand Pads

Foot Pads
Small: Shoe Size 1-2:
Medium: Shoe Size 3-4:
Large: Shoe Size 5-6:
X-Large: Shoe Size 7-8:
Shoe Size 9-10:
Shoe Size 11-12:
I plan to purchase them at class: I plan to purchase them at class:
I already have my hand pads! I already have my foot pads!


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