KMA Self Defense Academy & Fitness Center Registration Form

KMA Self Defense & Fitness Academy

Registration Form
Member Information
Member name*

First NameLast Name
Birth Date*

MonthDayYear
Gender

MaleFemale
Home Number

Area CodePhone Number
Cell Number

Area CodePhone Number
E-mail*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information (for students under 16years).
Name

First NameLast Name
Home Number

Area CodePhone Number
Cell Number

Area CodePhone Number
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the Student prescribed an inhaler? If yes, please explain any instructions.
Informed Consent and Acknowledgement

I, the undersigned, acknowledge and agree to my participation and/or the participation of my child in any and all activities conducted by KMA Self Defense Academy during the regular operation of the academy. In consideration of the acceptance of myself and/or my child as a participant in KMA Self Defense Academy, I assume all risks and hazards incidental to these activities and hereby release, absolve, and hold harmless KMA Self Defense Academy, its officers, agents, representatives, coaches, and affiliates from any and all liability for injuries sustained by myself and/or my child while traveling to, participating in, or returning from any scheduled sessions.

In the event of injury to myself and/or my child, I waive all claims against KMA Self Defense Academy, including but not limited to its coaches, affiliates, other participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of the premises used for training and events. I understand that participation in any physical activity, including Krav Maga, carries inherent risks. These risks include, but are not limited to, fractures, sprains, paralysis, or even death.

By signing below, I confirm that I have read and understand this acknowledgment of risk and consent to participation, either for myself or on behalf of my child.

Declaration:

I, First Name Last Name hereby certify to the best of my knowledge that the above information is true and accurate. I understand that in the event that any information is found to be false or misleading, the registration can be terminated and all fees forfeited at KMA's discretion. Any information provided to KMA Self Defense Academy will be treated with the strictest of confidence.

I understand that fees must be paid in full prior to attending the academy and that payment of fees confirms my registration and acknowledgement that I have read, understood and agreed to KMA Self Defense & Fitness Academy Terms and Conditions.

Date
Payment and Policy Information

There will be a one time registration fee of US$20.00. Please note: Spaces are limited and unreserved.

All prices are quoted in USD.

After 10 days you will be charged a late fee of US$25.00

We accept: Cash, Cheque, Third Party Transfer, Visa, Mastercard- Debit & Credit Card.

Please make cheques payable to Krav Maga Anguilla.
Memberships
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Registration Fee$20.00
One time payment.

Fitness Membership$120.00
48 classes, Unlimited

Pilates Membership$100.00
28 Classes Monthly

Self-Defense Group (Teens)$80.00
Monday Wednesday Friday -5:00pm

Self-Defense Group (Kids)$80.00
Ages 6+ Mon & Friday - 4:00pm Saturday -9:00am

Day Pass$15.00
Per Class

Self Defense/ Boxing Private$40.00
Should be Empty:

KMA Self Defense & Fitness Academy

Declaration: