Martial Arts Student Enrollment Agreement Form

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STUDENT ENROLLMENT AGREEMENT 
    
                 Stonetown Karate Centre Inc. 
   29 Wellington St. St.Marys, Ontario, N4Z 1A4 
                           519­284­0614 
                         email: info@stonetownkarate.ca 
 
Students Name: _________________________  
Do You Have any Previous Martial Arts Experience?  Yes or No  
Street Address: _________________________   
If You Yes what Style: ________________________________ 
City & Province: _________________________  
Do You Have any Current or Past Injuries Our Instructors Should 
Postal Code: ____________________________  
be aware of? ________________________________________ 
Home Ph.#:  ____________________________   
How Did You Hear of  Us? _____________________________ 
Date of Birth: _____________   Sex: ________   
Do You Know anyone Personally who is Involved with our School? 
Medical Alert: ___________________________  
_____________________________________________________ 
Elementary School: ______________________
 
 
 
Parents Names: _________________________ 
 To help assist us in reaching positive goals with your child please 
Street Address: _________________________  
 rate your child in the following areas. 
City & Province: _________________________  
Program Benefits                   Low         Average         High 
Postal Code: ____________________________ 
 Focus                                       ____        _______          ____ 
Home Ph.# ______________________________ 
Balance                                    ____        _______          ____ 
Work Ph.# ______________________________  
Self­Confidence                       ____        _______          ____ 
Cell Ph.# _______________________________  
Self­Discipline                          ____        _______          ____ 
Email: _________________________________   
Self­Esteem                             ____        _______          ____ 
Mothers Place of Employment: ____________    
Listening                                  ____        _______          ____ 
Fathers Place of Employment: _____________   
Fitness Level                          ____         _______          ____ 
 
 
Emergency Contact Information:                         
Are there any problems or special considerations our Instructors 
Names: ________________________________  
 should be aware of? __________________________________ 
Ph.# ______________ Cell Ph.# ____________ 
 
Please Choose the Program You are Interested in Enrolling in: 
Little Ninja Class (3­5 year old children) ______ 
Junior Karate Classes (5 years & Up)     ______ 
Adult Karate Classes                                 ______ 
Adult Cardio Kickboxing Class                ______ 
Belt Level Increase Summer Program    ______ 
Junior Summer Camp Program               ______ 
 
The Customer promises and agrees to pay the following monthly or program  fees by or on  the first day of each month prior 
to receiving any instruction for that month or period and agrees to continue on the same for each consecutive month. 
 
PROGRAM FEE/MONTHLY FEE: $____________      PROGRAM START DATE: ______________ 
 
Signed and Dated this _________day of ____________  Year ___________ 
 
MEMBERS/Guardian SIGNATURE _________________________________ 
(If under 18 years of age, this agreement must be signed by a parent or legal guardian) 
(I have read and understand this agreement & terms. Please read & sign back of sheet) 
 

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