Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact
*
First Name
Last Name
Emergency Contact's Phone
*
(###)
###
####
Emergency Contact's Email
Student's Name
*
First Name
Last Name
Birth Date
Please indicate the birth date of the student
MM
DD
YYYY
Student's Name
First Name
Last Name
Birth Date
Please indicate the birth date of the student
MM
DD
YYYY
Student's Name
First Name
Last Name
Birth Date
Please indicate the birth date of the student
MM
DD
YYYY
Student's Name
First Name
Last Name
Birth Date
Please indicate the birth date of the student.
MM
DD
YYYY
Are there any health issues, injuries or diagnosed special needs that we should be aware of?
*
Would you like to pay the down payment or the full tuition price?
*
This will influence the PayPal invoice you will receive once you submit this form.
Please indicate if you are purchasing multiple enrollment packages.
*
There is a 5% Family Discount available. Each family member would receive 5% off their individual tuition price.
The cost of equipment, including T-shirts, Uniforms, etc. are not included in the tuition costs
Are any of the students being enrolled one or more of the following options?
*
If any of the students being enrolled are a police officer, firefighter, paramedic or senior citizen, they are eligible for a discount on their individual tuition.
[Please read the following then fill in your name to indicate you have read and understand the agreement]. By signing this agreement, I understand that under the terms of the agreement, the school obligates itself to furnish me with professional instructions and suitable facilities for teaching lessons. All class sessions are supervised by qualified personnel trained in the procedures and traditions of the Martial Arts. The regular tuition is $250 per month, but a substantial discount has been provided to me by virtue of enrolling in a regular course. Student hereby represents that he/she is physically fit to take the prescribed course of instruction. I understand that my tuition is arranged to be made in monthly installments and is not affected by my lesson schedule and/or attendance. I understand and agree that the school will not be liable for any injuries, damages, loss, etc, NOT caused by or resulting from the negligence of the owners, operators, or persons in charge of such establishment, or employees. I acknowledge if a payment is not made within 10 days after it is due, I will be charged $5, or 5% of the amount in default. I will faithfully comply with all the rules and regulations of the school and the traditions of the Martial Arts. I further understand that failure to complete the lessons does not relieve me of my obligation to pay the tuition in full. As required by General Obligation Law, you have certain rights to cancel this agreement. These are set forth in an additional document, to be provided to you upon enrollment. You may cancel this agreement without any penalty or further obligation within three (3) business days from the date of this agreement. Notice of cancellation shall be sent to Martial Arts Institute of the Berkshires, either by mail or email. By signing below, you understand that you’ll receive a completed copy of this agreement and the rules and regulations.
*
