Fall Semester Registration
Please fill out the information below, choose the schedule that works best for your family-whether you’re looking for once or twice a week, a 6-week session, or a full semester of training. Our program is open to ages 4 and over, with morning and midday classes designed for homeschool families. Space is limited, so secure your spot today!
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*
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Last Name
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*
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Additional Sibling DOB
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Additional Sibling:
Additional Sibling DOB
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February
March
April
May
June
July
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September
October
November
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Parent/Legal Guardian Name
*
First Name
Last Name
Email Address:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Registration Package Options: (new students only)
*
Basic Registration Package ($90) - Includes t-shirt, hand wraps, boxing gloves
Complete Registration Package ($250) - Includes t-shirt, hand wraps, boxing gloves, shin guards, Muay Thai shorts
Returning Student
Please select your desired program:
*
6 Week Program 1x a week (August 26 - October 3, 2025)
6 Week Program 2x a week (August 26 - October 3, 2025)
Tiny's 6 Week Program (ages 4-5) 1x a week (August 27 - October 1, 2025)
Semester 16 Weeks (up to 3x a week) (August 25 - December 3, 2025)
Monthly Membership (1-3x a week options)
Preferred Class Days & Age Group:(If registering for more than 1x a week, select all days/times.)
*
Tuesday (10:00 AM, ages 6–10)
Tuesday (11:00 AM, ages 10+)
Tuesday (5:00 PM, ages 6+)
Wednesday (4:30 PM, ages 4-5)
Thursday (5:00 PM, ages 6+)
Friday (10:00 AM, ages 6–10)
Friday (11:00 AM, ages 10+)
Does student have any previous martial arts experience?
*
(If yes, please explain and duration)
What are your main goals for enrolling your child in this program? (Check all that apply)
Discipline
Improved Coordination
Self-defense skills
Social interaction
Strength
Balance
T Shirt Size
*
Please Select
Youth XS (4-5)
Youth Small (6-8)
Youth Medium (8-10)
Youth Large (10)
Youth XL
Adult Small
Adult Medium
Adult Large
T Shirt Size
Please Select
Youth XS (4-5)
Youth Small (6-8)
Youth Medium (8-10)
Youth Large (10)
Youth XL
Adult Small
Adult Medium
Adult Large
For Additional sibling
T Shirt Size
Please Select
Youth XS (4-5)
Youth Small (6-8)
Youth Medium (8-10)
Youth Large (10)
Youth XL
Adult Small
Adult Medium
Adult Large
For additional sibling
T Shirt Size
Please Select
Youth XS (4-5)
Youth Small (6-8)
Youth Medium (8-10)
Youth Large (10)
Youth XL
Adult Small
Adult Medium
Adult Large
For additional sibling
Does your child(ren) have any physical limitations or health concerns we should be aware of?
*
Does your child(ren) have any special needs or require accommodations? If yes, please describe.
*
How did you hear about our homeschool martial arts programs? (Check one)
*
Facebook
Instagram
Ad
Homeschool Co-op
Word of Mouth
Referral (please indicate who in other option)
Other
Is there any additional information you’d like us to know about your child(ren)?
1. Emergency Contact Information
Name
*
First Name
Last Name
Relationship to Student
*
Phone Number
*
-
Area Code
Phone Number
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Behavior Policy:
All students are expected to demonstrate respectful and appropriate behavior at Black Lotus Gym at all times. Please review these guidelines with your child. Violations may result in disciplinary action or removal from the program without a refund.Speak kindly and respectfully to others. Foul language, putdowns, or bullying will not be tolerated.Prioritize safety by following all gym rules and instructions from staff.Treat peers, equipment, and the facility with care and respect.Show respect to instructors and fellow students at all times.Aggressive or threatening behavior toward anyone will result in immediate removal from the program without a refund.Maintain a positive attitude and participate fully in all activities.
RELEASE, CONSENT AND WAIVER OF LIABILITY
By agreeing to his release, consent and waiver you (buyer) certify that you are at least 18 years of age as the participant or you are the parent/guardian of a minor participant under 18 years of age. READ CAREFULLY: I, being 18 or older, or the legal guardian of the above named person who is under 18, as a participant in Black Lotus Training Center, LLC. DBA Black Lotus Gym's program activities (“Program”), hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the Program, Black Lotus Training Center, LLC, and their respective employees, agents, representatives and volunteers (hereinafter referred to as “RELEASEES”) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me and/or my child, or to any property belonging to me and/or my child, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES or otherwise, while participating in the Program, or while in, on or upon the premises where the Program is being conducted, which includes on location and off location activities. Program Activities may include, but are not limited to the following: • MARTIAL ARTS TRAINING • PARENT'S NIGHT OUT EVENTS • COMPETITIONS - BOTH ON LOCATION AND OFF LOCATION, IN STATE AND OUT OF STATE • BIRTHDAY PARTY EVENTS • SUMMER CAMP EVENTS • SELF DEFENSE EVENTS
INDEMNIFICATION AND ACKNOWLEDGMENT OF RISK
I am fully aware of the risks and potential hazards connected with participating in the Program, including but not limited to, the risk of loss of personal property from theft, injuries associated with MARTIAL ARTS TRAINING, and other injuries that may not be foreseeable and I hereby elect to voluntarily participate or to have my minor child participate in the Program, and engage in such activity knowing that the activity may be hazardous to me and/or my child and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, that may be sustained by me and/or my child, or any loss or damage to property owned by me and/or my child, because of me and/or my child being engaged in such an activity, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES or otherwise.
ACKNOWLEDGEMENT OF GOOD PHYSICAL CONDITION
I further acknowledge that I and/or my child is in good physical condition and I do not know of any medical or physical condition or other reason that I and/or my child should not participate in the Program or which could interfere with my and/or my child’s safety in such Program, or else I am willing to assume—and bear the cost of— all risks that may be created, directly or indirectly, by any such condition. My and/or my child’s participation in any Program activity is purely voluntary, and I elect to have myself and/or my child participate despite the risks and known or unknown dangers associated with Program activities.
CONSENT TO MEDICAL TREATMENT
During the Program, I hereby give permission for the Program staff to administer appropriate medical attention to myself and/or my child in the event of any accident, illness, or injury, including non-prescription medications or any medications my child brings to class, camp or other events in original containers with dosage instructions that is provided to Program staff. In the event of an emergency, 911 will be called and I will be responsible for all costs of medical coverage and treatment provided not covered by my and/or my child’s insurance.
CONSENT TO PHOTOGRAPHY
I further hereby authorize Black Lotus Training Center, LLC DBA Black Lotus Gym to photograph and/or video record myself and/or my child during the Program, and use or distribute any picture or video related to Program activities that I and/or my child is depicted in. I also authorize use of these materials for publication in a brochure, on websites, or other promotional material and social media. They may also be distributed to other Program participants, including but not limited to a Program group picture of all participants.
APPROPRIATE CONDUCT
Black Lotus Training Center, LLC DBA Black Lotus Gym reserves the right to cancel any membership/trial/intro without refund for any reason, including but not limited to misconduct, rude/inappropriate behavior, disrespect, etc. from the student and/or parent, guardian or family member.
RELEASE AND WAIVER OF LIABILITY
I HEREBY EXPRESSLY RECOGNIZE AND ASSUME ALL RISKS ASSOCIATED WITH MY AND/OR MY CHILD’S PARTICIPATION IN THE PROGRAM AND VOLUNTARILY RELEASE, WAIVE, DISCHARGE, COVENANT NOT TO SUE AND HOLD HARMLESS THE RELEASEES. I AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEES from any loss, liability, damage or costs, including court costs and attorneys’ fees, that may incur due to my and/or my child’s participation in the Program WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES or otherwise. It is my express intent that this Participant Release, Consent and Waiver of Liability shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE the above-named RELEASEES. I hereby further agree that this Participant Release, Consent and Waiver of Liability shall be construed in accordance with the laws of the State of Florida. IN AGREEING TO THIS PARTICIPANT RELEASE, CONSENT AND WAIVER OF LIABILITY, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing, understand it and agree voluntarily as my own free act and deed; no oral representations, statements, or inducement, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent and/or I am the parent or guardian of the child participant, and I agree to this Participant Release, Consent and Waiver of Liability for full, adequate and complete consideration, fully intending to be bound by same. I agree to all terms and conditions on today's date and understand that my agreement remains in effect in perpetuity. By voluntarily checking the box “I agree.." and/or signing, I warrant that I have read, or have had read to me, the entire agreement and all of the forgoing: IN FULLY RECOGNIZING THAT IF ANYONE IS HURT OR PROPERTY IS DAMAGED WHILE I AM PARTICIPATING IN BLACK LOTUS TRAINING CENTER, LLC DBA BLACK LOTUS GYM, I WILL HAVE NO RIGHT TO MAKE A CLAIM AND FILE A LAWSUIT AGAINST BLACK LOTUS TRAINING CENTER, LLC DBA BLACK LOTUS GYM, ITS OFFICERS, AGENTS, LICENSED AFFILIATES, OR EMPLOYEES EVEN IF THEY OR ANY OF THEM NEGLIGENTLY CAUSED THE BODILY HURT OR PROPERTY DAMAGE and further agree that no oral representations, statements, or inducements, apart from the foregoing written agreement have been made. THE NAMED PARTICIPANT AND/OR THEIR LEGAL GUARDIAN authorizes Black Lotus Training Center, LLC DBA Black Lotus Gym to use, reproduce, and or publish all written and/or visual materials that may pertain to me. I understand that this material may be used in various publications, public affairs releases, marketing material, or for other related endeavors. I understand that by checking the box "I Agree..." and/or signing, I agree to opt in and subscribe to receive emails from Black Lotus Training Center, LLC DBA Black Lotus Gym until I unsubscribe.
PROGRAM TERMS & CONDITIONS
Completing this form does not guarantee a spot in the program.We will contact you within 24 hours of submission with next steps to complete registration. Limited spots available; first-come, first-served basis. No make-up classes for missed sessions. No refunds will be issued after the program starts. Missed classes cannot be made up. Parents/guardians are responsible for ensuring their child arrives on time and is picked up promptly after class.We reserve the right to modify the program schedule or curriculum as needed. By participating, you release Black Lotus Gym from any liability for injuries or damages.
(INITIAL IN BOX TO ACKNOWLEDGE)
*
I, the parent/guardian, hereby attest that I have carefully read this Permission to Participate, understand its contents, and agree to its terms and conditions.
*
I agree
Signature
Date
*
-
Month
-
Day
Year
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For EMA/PEP Scholarship Families
If you are paying for your child’s program using an EMA (PEP) scholarship: 1. Please select your desired registration and program/semester options. 2. Enter “PEP” in the coupon code box at checkout and proceed to submit your registration. 3. In your EMA portal, please search Black Lotus Gym and reserve your funds through your EMA portal for the selected registration & program amount. Your child’s spot in the program will only be confirmed once we receive notification that your funds have been reserved. If funds are not reserved in a timely manner, your registration may be released to another family. (If you have any questions about this process, please contact us at 561-740-6018 before completing your registration.)
My Products
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( X )
Basic Registration - Single Student
$
90.00
Includes registration, t-shirt, boxing gloves and hand-wraps
Quantity
1
2
3
4
5
6
7
8
9
10
Basic Registration - Two Students
$
162.00
Includes SIBLING (2) registration, t-shirt, boxing gloves and hand-wraps
Quantity
1
2
3
4
5
6
7
8
9
10
Complete Registration - Single Student
$
250.00
Includes registration, t-shirt, boxing gloves, hand-wraps, Muay Thai shorts and hard shin guards
Quantity
1
2
3
4
5
6
7
8
9
10
Complete Registration - Two Students
$
400.00
Includes two registration, t-shirt, boxing gloves, hand-wraps, Muay Thai shorts and hard shin guards
Quantity
1
2
3
4
5
6
7
8
9
10
6 Week Program 1x Class - Single Student
$
225.00
Includes 6 week program, 1x a week, single student
Quantity
1
2
3
4
5
6
7
8
9
10
6 Week Program 1x class - Two Students
$
405.00
Includes 6 week program, 1x a week, two students
Quantity
1
2
3
4
5
6
7
8
9
10
6 Week Program 2x Class - Single Student
$
400.00
Includes 6 week program, 2x a week, single student
Quantity
1
2
3
4
5
6
7
8
9
10
6 Week Program 2x Classes- Two Students
$
720.00
Includes 6 week program, 2x a week, two students
Quantity
1
2
3
4
5
6
7
8
9
10
Monthly Membership - 1x a week
$
109.00
Single Student, 1 class per week
Monthly Membership - 2x a week
$
159.00
Single Student, 2x class per week
Monthly Membership - 3x a week
$
200.00
Single Student, 3 class per week
2 Students Monthly Membership - 1x a week
$
199.00
Two Students, 1 class per week
2 Students Monthly Membership 2x a Week
$
259.00
Two Students, 2 classes per week
2 Students Monthly Membership - 3x a week
$
320.00
Two Students, 3 classes per week
Full Semester - Single student
$
800.00
16 week program, beginning week of August 25 - December 3rd. Up to 3 classes per week, single student
Quantity
1
2
3
4
5
6
7
8
9
10
Full Semester - Two students
$
1,280.00
16 week program, beginning week of August 25 - December 3rd. Up to 3 classes per week, two students
Quantity
1
2
3
4
5
6
7
8
9
10
Enter coupon
Apply
Total
$
0.00
Payment Methods
Credit Card
Apple Pay
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Cash App Pay
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ACH Bank Transfer
Afterpay
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