Registration Form

Date:_________________________________
Billing Name:___________________________
Student Name:_________________________
Select your program:
$60.00/ month plus HST:
Karate Kids (ages 4-7) Kardio Kickboxing

$75.00/ month plus HST:

Basic Training (8-12 years twice a week program)
Kick City Core Training (twice a week)

$100.00/ month plus HST:

Basic Black Belt Training (8-12 years up to 4 classes per week )
Kick City Core Training: (up to 4 classes per week plus Cardio Kickboxing)

Total Monthly Billing: $________________________________plus HST

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)
chequing / 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 #:__________________________ 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.