Basic Membership Enrollment

Basic Membership Enrollment

1 Member = $120 monthly / 2 Members = $200 Monthly.
Member's Name *

First Name Last Name
Birth Date

Month Day Year
Gender
2nd Member's Name

First Name Last Name
Birth Date

Month Day Year
Gender
Address *

Street Address

Street Address Line 2

City State

Zip Code
Student E-mail *
Mobile Number *

Area Code Phone Number
Your Course *

Course Price *

1 Member Basic Membership $ 120.00

Tuition runs automatically every month on the day of enrollment (if you sign up on the 7th then it will be on the 7th of every month). We do not use contracts so you can cancel at anytime.

Class T-Shirt Size

2 Member Basic Membership $ 200.00

1st Member T-Shirt 2nd Member T-Shirt

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

In consideration for my attendance and participation at Chesapeake Kung Fu/Tai Chi and Virginia Beach Kung Fu/Tai Chi, I, the student, acknowledge the existence of certain inherent risks in this type of training and hereby agree to assume all risks. I further relieve Chesapeake Kung Fu/Tai Chi and Virginia Beach Kung Fu/Tai Chi, and fellow students, from any liability resulting from personal injury or loss of personal belongings. I also state that I am physically fit to take the prescribed course of instruction and do so of my own free will. I will seek my doctor's approval if I have any physical concerns before participating in this type of training course *

I Agree to the Terms & Conditions above
Yours for Better Health, Greater Strength and Competent Skills.
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