Hanshi Jerry Piddington's
 AKANA Membership Application
School Charters/Individual Memberships/Rank Certificates
Please type name & rank as preferred on certificate:
First Name:
Middle Initial:
Last Name:
Email:
Age:
Date of Birth:
Gender: Male:  Female:
Home Phone:
Mobile Phone:
Mailing Address:
City:
Province/State:
Postal Code/Zip Code:
Training Time-In:
Rank (Kyu or Dan/Belt):
Style of Martial Arts:
Instructor's Name:
Name of  Dojo
Dojo Phone
Dojo Street Address:
Dojo City:
Dojo Province/State:
Dojo Postal Code/Zip:



Payment Information
 Click here for instructions

Please click appropriate boxes:

Yearly AKANA School Charters & Renewals:    Associate (AOS)   Affiliated (all styles)
  School Charter (includes 11 x 17 AKANA school charter certificate) - $150
  School Charter Renewal (due by March 31) - $100 / Add reinstatement fee after April 30 - $25
       (Renewal fee is waived for school that adds 10 or more new individual AKANA members within annual term)

AKANA Individual Memberships & Renewals:    New Membership   Renewal
  Mudansha/under Black Belt (includes AKANA patch & membership certificate) - $25
  Yudansha/Black Belt (includes AKANA patch & membership certificate) - $50
       (New membership requires copy of current rank certificate with a current photo)

AKANA Rank Certificates:  (Must be a current AKANA member)
(Associate American Open Style or Affiliate Rank Recognition)
  Kyu Belts, below Black Belt (includes 8½ x 11 AKANA certificate) - $15
  Shodan/1st Degree Black Belt (includes large 11 x 17 AKANA certificate) - $100
  Nidan/2nd Degree Black Belt (includes large 11 x 17 AKANA certificate) - $200
  Sandan/3rd Degree Black Belt & up (includes large 11 x 17 AKANA certificate) - $300       

Date Promoted:    Rank (Kyu or Dan/Belt Color):

  Please add extra charge for custom computerized calligraphy on kyu rank certificate - $2.50


Additional AKANA Patches:
  Please send additional beginner (red tomoe on white) AKANA patch(es)
  Please send additional intermediate (blue tomoe on white) AKANA patch(es)
  Please send additional advanced (white tomoe on blue) AKANA patch(es)
  Please send additional black belt (white tomoe on red) AKANA patch(es)
 @ $10 each for a total of $

Total amount of check or money order made payable to AKANA: $

Please print and mail application and current photo along with check or money order:
AKANA / P.O. Box 922 / China Grove, North Carolina  28023

If you have any comments or questions:
Call:  1-800-560-KICK
Email:   info@sidekickkarate.com