PARENT INFORMATION IF STUDENT IS UNDERAGE (18)

Aka To Kuro Martial Arts School LLC

Teaching Shodin Ji Do Karate

If you are not the child's parent or guardian please do not proceed with application.
STUDENT APPLICATION
Student Name*

First NameLast Name
Student Nickname: (If they have one)
If you are signing up multiple siblings, use this section:

First Name   Last Name   Date of Birth

First Name   Last Name   Date of Birth

First Name   Last Name   Date of Birth

First Name   Last Name   Date of Birth
Student Date of Birth*

MonthDayYear
How old is/are your child/ren?
Current address:*
City:
State:
PARENT INFORMATION IF STUDENT IS UNDERAGE (18)
Parent Name*

First NameLast Name
Parent Phone Number:*
Parent E- mail Address:*
EMERGENCY CONTACT
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to student:*
SPOUSE INFORMATION IF APPLICABLE
Spouse Name

First NameLast Name
Spouse Phone Number
Please enter a valid phone number.
Spouse Email Address
example@example.com
Media Release Form and Permission to Use Photography

Name of School: Aka To Kuro Martial Arts School LLC

Name of Style: Shodin Ji Do Karate

Subject: Classes, events, activities and programs specific to Aka To Kuro Martial Arts School LLC

Location: Aka To Kuro Martial Arts School LLC, at 1011 E Bender Hobbs, NM, and/or any deemed and specified locations, events, classes, programs or activity.

I grant to Instructor Esther C Bratcher (Senior Instructor and owner) of Aka To Kuro Martial Arts School LLC, its representatives, assistant instructors, employees, volunteers and designees the right to take photographs of me and my child/ren in connection with the above-identified subject. I authorize Aka To Kuro Martial Arts School LLC, its assignees and transferees to copyright, use and publish the same in print and/or electronically and/or for social media sites.

I agree that Aka To Kuro Martial Arts School LLC, may use such photographs of me and my child/ren with or without my name and for any lawful purpose, including, for example: such purposes as publicity, illustration, advertising, internet, and website content.
Do you approve of our Media Release Policy. *
Prayer and Pledge Policy
Medical Treatment Authorization Form

This form grants temporary authority to a designated adult to provide and arrange for medical care for a minor in the event of an emergency where the minor is not accompanied by either parents or legal guardians, and in the event it may not be feasible or practical to contact them.
Physician's Location of practice and contact information:
Physician's Name (if applicable)

First NameLast Name
Physician's Phone Number (if applicable)
Please enter a valid phone number.
Name of Hospital Clinic and/or Doctor
Allergies to Medications: (If NONE please type "NONE") If you have multiple kids please specify.*
AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)

I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for any adult instructor of Aka To Kuro Martial Arts school (hereafter "Designated Adult") to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Designated Adult to summon any and all professional emergency personnel to attend, transport, and treat the minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care. It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Designated Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel.
Allergies (Other): Please note all conditions for which the child is currently receiving treatment. If you have multiple kids please specify.
Let us know of any behaviors that will help us to better teach our new student. If you have multiple kids, please specify.
Tuition Fees
Tuition Cost, Auto Payment Policy and Agreement
Payment Withdraw:

My payment (plus tax) will be automatically withdrawn on the chosen date (choose the 1st or 5th) of every month. This cost is subjected to increase with a 1 month notice.
Please Choose One *
Tuition Fees:

2 classes a week for one student is $129.99 a month per student.

2 classes a week for two students is $106.99 a month per student.

2 classes a week for three siblings or more is $99.99 a month per student.
I will pay the agreed apon amount every month on my scheduled due date.

This amount will be automatically withdrawn from the credit/debit card I provide.

I will give a 15-day notice (email or text) of my cancellation to Aka To Kuro Martial Arts School LLC, to stop automatic withdraws.

I understand no refunds will be given after a charge has been processed.

Late Payment Policy:

If payment is more than 10 days late, a re-registration fee will be added to your next month tuition.

Registration Fee

A Registration fee of $50.00 will be paid for sign-up (for new students). If there's more than one student (multiple siblings) signing-up, only one sign-up fee will be charged
Service Disclosure:

Disrespectful behavior from any student and/or their parent/s will not be tolerated. We respectfully reserve the right to refuse service to any student, at any time in their martial arts career.

If the student needs to skip a month with plans to return, there will be a re-registration fee of $50.00. (if you have mulitple kids there will only be one $50 fee. not $50.00 per student).
Testing fees:

See "Testing Fees" in our communication app.

These tests and costs are spread out over a minimum of six years.

The credit card on file will be charged one day prior to test if fee is not paid in advance.
Printed Name of Parent*
Signature (if minor) of Parent or Legal Guardian*

Powered by Jotform SignClear
Printed Name of Second Parent (Optional)
Signature (if minor) of Second Parent or Legal Guardian (Optional)

Powered by Jotform SignClear
By Clicking "SUBMIT" I understand and agree to all Aka To Kuro Martial Art School LLC's "Student Application". If I have any questions or do not understand, I will ask prior to submitting this application.
Should be Empty:

STUDENT APPLICATION

PARENT INFORMATION IF STUDENT IS UNDERAGE (18)

EMERGENCY CONTACT

SPOUSE INFORMATION IF APPLICABLE

Prayer and Pledge Policy

Tuition Fees

Tuition Cost, Auto Payment Policy and Agreement