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

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.