Giammalva Prep Enrollment Application

1

Family Name ( Last Name )* This field is required.

2

Father's Name* This field is required.

3

Mother’s name* This field is required.

4

Student Name* This field is required.Info for player 1

First Name

Last Name

5

Student Birth Date* This field is required.Info for player 1

6

Allergies and/or Medications* This field is required.Info from player 1

7

What is the student's learning style?* This field is required.

8

What is the student's favorite subject?* This field is required.

9

What is the student's least favorite subject?* This field is required.

10

What is something your teachers should know about you?* This field is required.

11

Did the student receive any education services such as (504, Special Ed, etc.) If so, what services?* This field is required.

13

What is your preferred payment plan?

Pay in full

Pay in 3 Installments

Pay in 10 Installments with a 10% convenience fee

14

Address* This field is required.

Street Address

Street Address line 2

City

State / Province

Postal / Zip Code

Country

15

Father's Phone Number* This field is required.

Area Code

Phone Number

16

Mother's Phone Number* This field is required.

Area Code

Phone Number

17

Father's Email* This field is required.

example@example.com

18

Mother's Email* This field is required.

example@example.com

20

Are you interested in participating in our Athletic Development program?* This field is required.To help you improve your sport

Yes

No

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AUTOMATED CHARGE DEBIT/DRAFT DRAW AUTHORIZATION* This field is required.I REALIZE ALL PROGRAM FEES AND PROGRAM GUEST FEES INCURRED BY MY FAMILY WILL BE AUTOMATICALLY DRAFTED FROM MY CHECKING/CHARGE ACCOUNT. I ALSO REALIZE THAT I MAY CANCEL MY CHILD’S PROGRAM BY GIVING WRITTEN NOTICE AT LEAST TEN (10) DAYS BEFORE THE NEXT MONTH PROGRAM START DATE. I HAVE GIVEN AUTHORIATION TO THE INSTITUTION/CARD LISTED BELOW TO HONOR PREAUTHORIZED CHECK/CHARGE TRANSACTION DRAWN BY GIAMMALVA RACQUET CLUB. I REALIZE THAT MY BANK/ACCOUNT STATEMENT WILL CONSTITUTE RECEIPT FOR PAYMENT. I ALSO REALIZE THAT IF PRE-AUTHROIZED CHECK/CHARGE IS NOT HONORED BY SAID INSTITUTIONS, I AM RESPONSIBLE FOR TOTAL PAYMENT BY OTHER MEANS OF TRANSACTION. AS A CONVENIENCE TO ME, I HERBY REQUEST AND AUTHORIE YOU TO PAY AND CHARGE MY CHECK/CHARGE DRAW ON MY TRANSACTION. AS A CONVENIENCE TO ME, I HERBY REQUEST AND AUTHORIZE YOU TO PAY AND CHARGE MY CHECK/CHARGE DRAW ON MY ACCOUNT BY AND PAYABLE TO THE ORDER OF GIAMMALVA RACQUET CLUB PROVIDED THERE ARE SUFFICIENT FUNDS/CREDIT IN SAID ACCOUNT TO PAY SAME ON PRESENTATION. I AGREE THAT YOUR RIGHTS IN RESPECT TO EACH DEBIT SHALL BE THE SAME AS IF IT WERE A CHECK/CHARGE DRAWN ON YOU AND SIGNED PERSONALLY BY ME. THE AUTHORITY IS TO REMAIN IN EFFECT UNTIL REVOKED BY ME WITH A TEN-DAY WRITTEN NOTICE AND UNTIL YOU RECEIVE SUCH NOTICE. I AGREE THAT YOU SHOULD BE FULLY PROTECTED IN HONORING SUCH CHECK/CHARGE.

Clear

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TERMS AND CONDITIONS * This field is required.1. RESIGNATION AGREEMENT: IT IS AGREED THAT APPLICANT MAY RESIGN FROM THE PROGRAM BY GIVING (10) DAY WRITTEN NOTICE BEFORE NEXT MONTH PROGRAM START DAY IN WRITING TO THE CLUB. THE EFFECTIVE DATE OF THE RESIGNATION WILL BE THE DATE THE CLUB RECEIVES APPLICATNS WRITTEN NOTICE. ALL ACCURED PROGRAM FEES AND OTHER CHARGES FOR WHICH APPLICANT IS LIABLE ARE DUE UPON THE EFFECTIVE DATE OF RESIGNATION. 2.MAKEUP AGREEMENT: CLASSES MISSED DUE TO STUDENT ILLNESS, VACATION, AND/OR OTHER PERSONAL REASONS WILL NOT BE MADE UP. IF A STUDENT HAS AN EXTENDED MEDICAL CONDITIONS OR EMERGENCY, PLEASE CONTACT THE CHIEF OF SCHOOL. 3.PAYMENT AGREEMENT: APPLICANT AGREES TO PAY THE ACCOUNT WHEN DUE. APPLICANT AGREES THAT THE CLUB MAY ASSESS A LATE CHARGE OF $25.00 FOR PAST DUE ACCOUNTS. 4.DISCLAIMER AND HOLD HARMLESS AGREEMENT: I ACCEPT FULL RESPONSIBILITY FOR MY USE, HEIRS, AND ASSIGNS USE APPARATUS, APPLIANCES, FACULTY PRIVILEGE OR SERVICE WHATSOEVER, OWNED AND OPERATED BY THE CLUB, AT MY OWN RISK, AND SHALL HOLD THIS CLUB, ITS SHAREHOLDERSR, DIRECTORS, OFFICERS, EMPLOYEES, REPRESENTATIVES, AND AGENTS HARMLESS FOR ANY AND ALL NEGLIGENCE, LOSS, CLAIM, INJURY, DAMANGE, OR LIABILITY SUSTAINED OR INCURRED BY ME RESULTING THEIR FORM. 5.PHOTO RELEASE: I GIVE MY PERMISSION TO GIAMMALVA RACQUET CLUB TO PHOTOGRAPH/VIDEO AND/OR USE A PHOTOGRAPH OF ME, MY FAMILY, AND CHILDREN IN PUBLICATIONS, NEWS RELEASES, OR GIAMMALVA RACQUET CLUB WEBPAGE, CLUB NEWSLETTERS, BROCHURES, ETC.

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THANKS FOR CHOOSING GIAMMALVA PREP by AESA!

A staff member will contact you to collect your method of payment.