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 Book  Radio/TV  Facebook

 Newspaper  Demo  Google
 Sign  Birthday Party  Referral: ___________

Select your program:

 Karate Kids ages 4-7
1 class/ week $40.00
 Karate Kids ages 4-7
2 classes / week $60
(highly recommended)
 Youth Basic Training * All prices are subject
for ages 8-12 years to HST.
2 class/week $75
** Please subtract 50%
 Youth Accelerated on second, third family
Basic Training Program (must reside in same
up to 4 classes/ week household) member
$100 (recommended)
Total Monthly Billing:
$____________________________
plus HST
 Notice of Risk & Liability Waiver
In consideration for my child’s or children’s attendance and participation in the martial arts
training 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.