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)