Download - Kick City Master Child Registration Form
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8/8/2019 Kick City Master Child Registration Form
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Child Guest Registration Form
Student Name: _________________________________________ D.O.B.: ____________________ M/F: ___________
Mother (Guardian): _____________________________________ Occupation: ________________________________
Father (Guardian): ______________________________________ Occupation: ________________________________
Home #: _______________________ Cell #: ________________________ email: ______________________________
Address: ____________________________________________________________________________________
City: ___________________________________________ Postal Code: ___________________________________
How did you happen to hear about us:
Phone BookNewspaperSign
Radio/TVDemoBirthday Party
FacebookGoogleReferral: ___________
Select your program:
Karate Kids ages 4-71 class/ week $40.00
Karate Kids ages 4-72 classes / week $60
(highly recommended)
Youth Basic Trainingfor ages 8-12 years
2 class/week $75
Youth AcceleratedBasic Training Program
up to 4 classes/ week
$100 (recommended)
* All prices are subject
to HST.
** Please subtract 50%
on second, third family
(must reside in same
household) member
Total Monthly Billing:
$____________________________
plus HST
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8/8/2019 Kick City Master Child Registration Form
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Notice of Risk & Liability Waiver
In consideration for my childs or childrens attendance and participation in the martial artstraining offered by Kick City Martial Arts Fitness, I acknowledge the existence of certain
inherent risks in this type of training and hereby agree to assume all risks. As guardian, I further
relieve the school, its management, assigned staff, and fellow students from liability resulting
from loss, whether personal belongings or bodily injury. I also hereby state that he/she is
physically fit to take the prescribed course of instruction and does so of his/her own free will in
exchange for an agreed upon fee. I understand there is no refund policy on any monies I will
pay to Kick City Martial Arts Fitness.
Signed: ______________________________________________Date:_______________________________
Relationship to child: ___________________________________
Pre- Authorized Billing Service:(PLEASE PRINT)
I, __________________________________ hereby authorize Kick City Martial
Arts Fitness or its agents to use pre- authorized payments from my (please circle
one of the following) cheque / savings / credit card account as the method of
payment for my tuition. Monthly payments of $__ ______ plus HST will be
processed on the _______________ of each month. I agree that the pre-
authorized payments will continue until I give Kick City Martial Arts Fitness or its
agents 30 days written notice to cancel this agreement and only after the tuition
is paid in full. Billing service begins on ____________________.
Credit card Type:__________________________
Credit Card #:___________________________ Expiration Date:______________
Signature:________________________________________________________
*Please note that for chequing and savings account option, we require a void cheque or pre authorized
payment form (usually available through your bank or credit union).Please return this completed form
to Kick City.