Martial Arts Course Registration Form

DYNAMIC KARATE ACADEMY Registration Form
Adress:- 4708 Ave Van Horne,Montreal Quebec, H3W 1H7(FAMAS CENTER)

Contact:- (438)-884-9849/ (438)-927-8910/ (514)-649-2921/ (514)-777-7365

Sensai- Parshu Ram Bastola (4th Dan Black Belt) Shito Ryu Karate Canada(450)-560-2158

Email:- dynamiquekarateacademy@gmail.com

Website:- www.academydekaratedynamique.com

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Athlete Information
Athlete's Informations

First NameLast Name
Birth date

DayMonthYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family duo discount
Member of ANQ (Association of Nepalese in Québec)
Class schedule for the 12 -week session, from April 04 to 21 june 2026.*
Current level
Children 4 years and older as well as adults
prevnext( X )
Beginner White Belt (One class per week)$240.00 CAD
Class schedule for the 12 week session, from 4th April to 21 June*

Beginner White Belt (Two classes per week)$408.00 CAD
Class schedule for the 12 week session, from 4th April to 21 June*

For the 22-week in a year (One classes per week)$352.00 CAD
Class schedule for the 22-week session, from 3rd Jan to 31 May*

For the 22-week in a year (Two classes per week) $616.00 CAD
Class schedule for the 22-week session, from 3rd Jan to 31 May*

Intermediate: Orange to Green Belt (One class per week)$300.00 CAD
Class schedule for the 12 week session, from 4th April to 21 June*

Intermediate: Orange to Green Belt ( Two class per week)$528.00 CAD
Class schedule for the 12 week session, from 4th April to 21 June*

For the 22-week year (Two classes per week) $880.00 CAD
Class schedule for the 11-week session, from 22-week session, from 3rd Jan to May 31 *

Advanced: Green Belt and above (Two classes per week) $720.00 CAD
Class schedule for the 12 week session, from 4th April to 21 June*

Advanced: Green Belt and above (22-week year two classes per week) $1,100.00 CAD
Class schedule for the 22-week session, from 3rd Jan to 31 May.*

Total $0.00 CAD
Contactless payment method preferred

Interac e-Transfer (Email: dynamiquekarateacademy@gmail.com)

password: Karate

Shitoryu Karate Canada affiliation fee 40$ per Year. (Obligatory for insurance)

The fee for the Karate Passport (SKQ) for orange belt and above is $35, payable only once for life.
Parent/Guardian Information (if athlete is under 18)
Father/Mother*

First NameLast Name
Mobile Number

Phone NumberPhone Number
E-mail
Alternative Emergency Contact
Emergency Contact's Name

First NameLast Name
Mobile Number

eg 021Phone Number
Does the athlete have asthma, allergies, or any other medical condition? If yes, please describe.
Has the player received a prescription for an inhaler?
Payment option
Acknowledgement

I understand that all sports carry a risk of injury and that Dynamic Karate Academy is not responsible for injuries or loss suffered as the result of participating in these activities.

From time to time DKA will post photographs of our athletes, coaches, and supporters online. I will let Dynamic Karate Academy know by email if I do not consent to my or my child’s photos being shared.

Dynamic Karate Academy will give 30 days written notice of any fee increase.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature
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