Membership Club Membership Registration Form Families MUST submit information for EACH member. All fields marked with an asterisk (*) are required. New students must be at least Seven (7) Years Old. Membership Fees Annual Discounts (1-Free Month) Individuals $22.00 / month $242.00 / year Families $22.00 / month for 1st family member $11.00 / month for each additional family member $242.00 / year for 1st family member $121.00 / year for each additional family member Northglenn Judo Club is a registered member of USA Judo and all members are required to purchase insurance through a USA Judo membership. Click here to purchase a USA Judo membership which is valid for one year from the date of purchase. How many do you want to register?One (1)Two (2)Three (3)Four (4)Five (5)Six (6)Seven (7)Eight (8)Are ANY of these under the age of 18?*New students must be at least Seven (7) Years old No Yes Name of Legal Guardian* First Name (1)* Last Name (1)* Gender (1)* Male Female Date of Birth of 1st Member (MM/DD/YYYY)* First Name (2)* Last Name (2)* Gender (2)* Male Female Date of Birth of 2nd Member (MM/DD/YYYY)* First Name (3)* Last Name (3)* Gender (3)* Male Female Date of Birth of 3rd Member (MM/DD/YYYY)* First Name (4)* Last Name (4)* Gender (4)* Male Female Date of Birth of 4th Member (MM/DD/YYYY)* First Name (5)* Last Name (5)* Gender (5)* Male Female Date of Birth of 5th Member (MM/DD/YYYY)* First Name (6)* Last Name (6)* Gender (6)* Male Female Date of Birth of 6th Member (MM/DD/YYYY)* First Name (7)* Last Name (7)* Gender (7)* Male Female Date of Birth of 7th Member (MM/DD/YYYY)* First Name (8)* Last Name (8)* Gender (8)* Male Female Date of Birth of 8th Member (MM/DD/YYYY)* Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*This phone number is your:* Cell Home Other Email* Enter Email Confirm Email Do you have health insurance?* Yes No Phone Number of Emergency Contact*First Name of Emergency Contact* Last Name of Emergency Contact* NameThis field is for validation purposes and should be left unchanged. Δ