PMA Member Sign-Up

Plainville Martial Arts

NewRenewalReplacement/Upgrade
Salesperson's Initials
Account #
Buyer's First Name*
Buyer's Last Name*
Birth date*

MonthDayYear
Buyer's DOB
E mail address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Zip Code*
Occupation*
Cell Phone #*
Secondary Emergency Contact Name*
Secondary Emergency Contact Relationship To Student*
e.g. "Father" or "Grandmother"
Secondary Emergency Contact Phone #*
Today's date is

MonthDayYear
Date
I would like my agreement to begin on this date:

MonthDayYear
Date
and expires on
Non-Buyer Member #1 First Name (if applicable)
A "non-buyer member" would be any child, spouse, etc. of the person who pays for the membership
Non-Buyer Member #1 Last Name (if applicable)
Non-Buyer Member #1 Date Of Birth (if applicable)

MonthDayYear
Date
Non-Buyer Member #2 First Name (if applicable)
Non-Buyer Member #2 Last Name (if applicable)
Non-Buyer Member #2 Date Of Birth (if applicable)

MonthDayYear
Date
Membership Type*
# || adult / 8-12yo / 4-7yo || duration
Confirm # Of Months Of Initial Commitment
Example: "12" or "6" (match Membership Type, above)
I would like to pay my monthly dues via:*

Electronic Funds Transfer (EFT) from my Bank AccountElectronic Funds Transfer (EFT) from my Credit Card
Thank you for filling out this form!

This form pre-populates our PMA membership agreement with all of your pertinent information.

What we do next:

We will print your completed agreement, and have it on hand at PMA.

What YOU should do next:

Please set a time to meet with us, by texting 860-386-8326 or emailing info@plainvillemartialarts.com

In that meeting, we'll complete this form with your signature, and payment information, and your PMA membership will be activated!
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