After School Program

After School Program
Childs Name*

First NameLast Name
Student School*
Student Grade*
Parent/Guardian Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Single Student - $99 A Week

Two Students - $185 A Week

3+ Students - Aditional $20 A Student (If Same School)

Elite/GI Training - $10 A Week
2023 - 2024 Fee Schedule

Single StudentTwo Students3+ Students
Snack Shack ($10)

YesNo
Shirt QTY & Size
Please initial the following agreements for our After-School MMA:

*Please note-American Mixed Martial Arts LLC is not a childcare facility*

Please select and initial your billing choice
Please initial the following agreements for our After-School MMA:
Signature Our After-School MMA lasts the duration of a school year.
There is a MANDATORY 2-week cancellation notice. You are responsible for the
tuition during the 2-week notice whether your child attends or not.
Signature Tuition is due NO LATER than WEDNESDAY for the current week.
If tuition is not paid by WEDNESDAY of the current week due, I First Name Last Name hereby authorize
American Mixed Martial Arts LLC to charge my credit/debit card the following
week for the tuition due plus a $25 late fee.
Signature Tuition is due EVERY week, even if your child is not
attending. We DO grant ONE vacation week per school year in which tuition does
not have to be paid. This week must be signed up for at the front desk (15)
days in advance.
Signature There is NO discount or prorated payments for missed days in a week.
Signature A uniform shirt is required for every class. If your child does not have a uniform shirt, we will provide one and charge the card that is on file.
Signature We are not responsible for lost and stolen items
Signature We accept Cash, Check, and all major credit cards for
tuition payments. There will be a $25 returned check fee for all checks. Should
a check be returned twice, cash, money order or a credit/debit card will be the
only acceptable forms of payment.
Signature If your child will not be attending his/her school on a
particular day and does not require pickup or transportation to our facility,
we do require a notification prior to 12:00pm on the day of absence. Failure to
do so will result in a warning on the first offense and a $15.00 fee for each
additional offense.
Signature A school uniform MUST be worn in EVERY class that your child
attends. If your child does not have a uniform, they will not receive
attendance credit for that day. If the minimum attendance is not met, your
child will NOT be able eligible to test for their next belt rank. Additional
uniforms are available for purchase at our Pro-Shop.
Signature Children will be allowed to choose what room they want to go
into without assumption of supervision.
Signature Any outstanding balances that are left unpaid will be turned
over to our attorney for immediate collection. Any court costs, filing fees,
attorney fees or other related fees associated with the collection of unpaid
balances will be at the expense of the member.
Signature I hereby grant permission to the rights of my child’s image, likeness and sound of his/her voice recorded on audio or video tape without payment or any other consideration. I understand that the image may be edited, copied, exhibited, published, or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.
By signing this agreement, I First Name Last Name agree to all the terms and conditions laid out by American Mixed Martial Arts LLC. I hereby acknowledge that a staff member of AMMA has reviewed and explained the information contained in this agreement. I understand that AMMA does not accept pro-rated payments for any days/weeks missed. I am obligated to pay my balance in full. I understand that my child must follow facility rules. Furthermore, I acknowledge and understand that tuition payments are due by Wednesday of the current week for childcare services to be rendered for the following week. AMMA reserves the right to charge a $25 late fee if the payment schedule is not received on or before Wednesday of the current week. If the full balance is not paid prior to the following week, AMMA reserves the right to suspend services due to nonpayment.
Please select and initial your billing choice:
Signature I hereby authorize American Mixed Martial Arts (AMMA) to automatically withdraw my tuition as per this agreement on Monday of each calendar week.
Signature I hereby acknowledge and authorize American Mixed Martial
Arts to charge my debit/credit card at the end of the business day Friday in
the event that a payment for services has not been made prior to Friday of the current week for services already provided for the current week. This card will be kept on file and in safe keeping with AMMA. It will only be utilized for tuition
payments, any late fees and/or outstanding balances that may have accrued in
the account. ***$10 In House Fee Applies ***
Signature

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Card Information

Contact Information
Parent/Guardian's Name*

First NameLast Name
Childs' Name*

First NameLast Name
Home Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about our program?
Program you are interested in participating in*

After School Pick-upSummer Camp Martial ArtsAdult Martial ArtsMixed Martial Arts
Child's full legal name*
DOB*
Child's preferred name*
Sex*
Mother's Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Place Of Employment
Work Phone Number
Please enter a valid phone number.
Additional Phone Number
Please enter a valid phone number.
Best Time To Reach You

Hour Minutes

AM/PM Option
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Place Of Employment
Work Phone Number
Please enter a valid phone number.
Additional Phone Number
Please enter a valid phone number.
Best Time To Reach You

Hour Minutes

AM/PM Option
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other household adults
The child will be released only to the person(s) authorized, or in the manner authorized in writing, by the custodial parent(s) or legal guardian(s). The following people are authorized to remove the child from the facility in case of illness, accident or emergency, if for some reason the custodial parent(s) or legal guardian(s) cannot be reached;
Name
Phone Number
Please enter a valid phone number.
Name
Phone Number
Please enter a valid phone number.
Child’s Physician
Phone Number
Please enter a valid phone number.
Child’s Dentist
Phone Number
Please enter a valid phone number.
Has the child had:

SurgerySerious Illness/AccidentBurnsAllergiesConvulsions
List all identifying scars, birthmarks, skin discolorations:
Special needs of child
Child’s habits, fears, etc.
Previous after school/group experience
I give permission to consult the child’s physician resource listed above in case of emergency if I/we cannot be reached.

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Permission to Ride Form
School Name
I (we) hereby grant permission for First Name Last Name to ride to the After School Program or daily field trips in our Summer Camp located at 10450 66th St N, Unit 1 in Pinellas Park, FL 33782 on the following days:
Days

MondayTuesdayWednesdayThursdayFriday
Students will be traveling in the following manner: School Bus/Private Passenger Van/Private Passenger Vehicle
1. I authorize After School Program representatives to obtain medical treatment for my child in case of serious illness or injury and agree to pay for such treatment.
2. I understand that the certified After School Employee who usually dispenses the medications may or may not be present during this trip. Medications will be dispensed by a responsible staff member.
3. I have documented below all precautions and instructions regarding my child’s medication. I have noted any special health-related conditions or allergies regarding my child.
Date

MonthDayYear
Date
Signature of Parent/Guardian

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Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Alternate Emergency Contact

First NameLast Name
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.

Release For Emergency Care
I hereby give my consent to any emergency facility and physician to administer necessary treatment to my child First Name Last Name in the event of an emergency at which time I cannot be reached. I give consent to transport by ambulance if the situation warrants it.
Family Physician Name/Health Care Resource
Telephone Number
Please enter a valid phone number.
Allergies:
Date of Last DPT or Tetanus:
Insurance Company Covering Child:
Policy Number:
Group Number
Signature of parent or guardian*

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Date*

Waiver & Release of Liability
Student Name

First NameLast Name
American Mixed Martial Arts (AMMA) urges you and all students to obtain a physical examination from a doctor before using any exercise equipment or participating in any exercise, activity, or MMA class. All activities, including the use of strength training equipment and use of any and all machinery, equipment and apparatus shall be at the student’s sole risk. Student understands that the agreement to use or selection of exercise programs, after school programs, summer camps, MMA programs, methods and types of equipment shall be students entire responsibility, and AMMA shall not be liable for any claims, demands, injuries, damages, or actions arising due to injury to student’s person or property arising out of or in connection with the use by student of the services, facilities, and premises of the school. Student hereby holds the school, its officers, owners, agents, and employees harmless from all claims which may be brought against them by student or on student’s behalf for any such injuries or claims. Students participating in After School programs or Summer Camps understand that pick up and transportation to and from AMMA is also included. Parents and or students understand that there are risks involved with transportation and care for children and waive liability to all members of AMMA including officers, owners, agents, and employees harmless from all claims which may be brought against them by student or on student’s behalf for any such injuries or claims in regards to transportation or related outings to After School programs or Summer Camps with AMMA.
Signature (Parent Or Guardian)*

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Date*
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After School Program

Contact Information

Mother's Information

Father's Information

Permission to Ride Form

Child Health & Development Questionnaire

Release For Emergency Care

Waiver & Release of Liability