[Silvera Karate Jitsu] New user account

Silvera Karate Jitsu

Carter Dozier has just created an account on Silvera Karate Jitsu.

Here is the submitted registration form:

User registered date: 11:04 pm

Form: Default Registration – Form ID#: 1020

Username: Cdozier

Full Name: Carter Dozier

Birth Date: 2024/06/19

Gender: Male

Phone Number: 4242168598

E-mail Address: mizztoya3@yahoo.com

Full Address: 28253 Deplanche Lane Inkster, MI 48141

Emergency Contact Name: LaToya Richard

Relationship to Student: Mother

Emergency Contact Phone: 4242168598

Do you have prior Karate experience?: No

If yes, please specify your belt level and years of experience: (empty)

Do you have any medical conditions or allergies we should be aware of?: No

If yes, please specify: (empty)

Read Terms and Conditions: Yes

Printed Full Name (as your digital signature): Carter Dozier

Thank you!