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Adult Guest Registration Form

Student Name: _________________________________________ D.O.B.: ____________________ M/F: _______

Spouse: _____________________________________ 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:

 Cardio classes $60  Black Belt Training


Unlimited Cardio Karate, Weapons,
Classes CORE & CARDIO
60.00/ month $125
Total Monthly Billing:
(best results) * All prices are subject
$____________________________
 Kick City CORE to HST. plus HST
2 class/week $75
** Please subtract 50%
 CORE Accelerated on second, third family
Training Program (must reside in same
unlimited CORE + household) member
cardio classes
$100 (recommended)
Notice of Risk & Liability Waiver
In consideration for my attendance and participation in the martial arts training
offered by Kick City Martial Arts Fitness, I acknowledge the existence of certain
inherent risks n this type of training and hereby agree to assume all risks. 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 I am physically fit to take the prescribed course of
instruction and do so of my 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:_______________________________

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.