Student Application 2025

Name of Student

First NameLast Name

Nickname (if applicable)

Date of Birth

Date

WHEN SIGNING UP MULTIPLE STUDENTS:
First Name   Last Name   Date of Birth
First Name   Last Name   Date of Birth
First Name   Last Name   Date of Birth

Name of Parent or Legal Guardian

First NameLast Name

Phone Number

Please enter a valid phone number.

Email*

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of 2nd Parent or Legal Guardian (if applicable)

First NameLast Name

Phone Number

Please enter a valid phone number.

Email

example@example.com

Emergency Contact

First NameLast Name

Phone Number

Please enter a valid phone number.

Email (optional)

example@example.com

Relationship to Student

Does your kid/s attend any other types of Martial Arts, boxing or sports? If so, please specify:

Medical Treatment Authorization Form

This form grants temporary authority to a designated adult to provide and arrange for medical care for a minor in the event of an emergency where the minor is not accompanied by either parents or legal guardians, and in the event it may not be feasible or practical to contact them.

Allergies(Other): Please note any conditions (adhd ect) for which the child is currently receiving treatment for. This helps us with teaching them. If you have multiple kids please specify.

Let us know of any behaviors that will help us to better teach our new student/s. If you have multiple kids, please specify.

Select a Payment Date

Payment Withdraw:

Payment (plus tax) will be automatically withdrawn on the chosen date (choose the 1st or 5th) of every month.

I will pay the agreed upon amount every month on my scheduled due date.

This amount will be automatically withdrawn from the credit/debit card I provide.

To cancel membership and stop automatic withdraws, a 7-day notice (email or text) sent to Aka To Kuro Martial Arts School LLC, is required.

I understand no refunds will be given after a charge has been processed.

Tuition increase rates are effective for January 2025:

Service Disclosure:

Disrespectful behavior from any student and/or their parent/s will not be tolerated. We respectfully reserve the right to refuse service to any student, at any time in their martial arts career.

Name of Parent

First NameLast Name

Signature

Name of 2nd Parent (if applicable)

First NameLast Name

Signature

Student Application

MONTHLY TUITION