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2026 New / Renewal Membership Form

Please complete the following form.

If you have any changes after submitting this form, please let us know via email at member.urasenkehawaii@gmail.com.

New/Renewal (Choose One)*

New

Renewal

Notification Preference (Choose One)*

Email

U.S.Postal Service

Your Information

Please enter your name in Japanese and English below.

Kanji/Kana Given Name

Kanji/Kana Middle Name

Kanji/Kana Family Name

English/Romaji Given Name *

English/Romaji Middle Name

English/Romaji Family Name*

Title

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Phone*

Email*

Gender

Birthday (mm/dd/yyyy)

Language (Native)

Language (2nd)

Nationality

Do you currently take lessons from an instructor?*

Yes

No

Current Instructor Name

Your Highest License Level (Choose One)*

Highest License Level Permitted Date (mm/dd/yyyy)

Membership Fee (Select One)*

[Fee Level 1] Kyoju and above Licensed Member $100

[Fee Level 2] Chamei or Junkyoju Licensed Member$70

[Fee Level 3] Regular or Licensed Member up to Sei-hikitsugi$50

[Fee Level 4] Student member (High School and below)$20

*Online payments incur a 4% convenience fee.

*If you are student member and request for fee waiver, please email member.urasenkehawaii@gmail.com for Student Membership Fee Waiver Form.

Romaji Chamei

Kanji Chamei

Instructor Status

I have students.

I do not have students.

Have you attended Midorikai?

Yes

No

If Yes, please write the period of study in Midorikai. (e.g. 2024 - 2025)

Have you attended Urasenke Gakuen?

Yes

No

If Yes, please write the period of study in Urasenke Gakuen. (e.g. 2024 - 2025)

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urasenkehawaiiassociation@gmail.com

2454 South Beretania Street Suite 401

Honolulu, HI 96826 U.S.A.

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