Prairie Aikikai Registration Form

Student Registration Form

Revised January 1, 2004

27499 Five Points Road
Sycamore, Illinois 60178-9042
Tel: (815) 895-0345

All Prairie Aikikai members, continuing and new, are requested to complete all of the information on this registration form. Having this information in our computer files makes it possible to keep track of all of your practice and promotions. Thank you.

ID Number:

Name:

Address:

Home Phone:

Work Phone:

E-Mail:

If you are a new student, how did you find out about the Prairie Aikikai?

Newspaper Ad	Poster or Flyer
Web site	Aikido Today Magazine
Friend or Relative	Other (please describe)

Have you practiced Aikido elsewhere? Yes No

If YES,

at what dojo?
your Sensei's Name:
your current rank?
date promoted