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

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family duo discount

2nd people 10%3rd people or more 15%
Class schedule for the 11-week session, from October 5th to December 14th.*

Saturday (8:00-9:00)Saturday (9:00-10:00)Sunday (8:00-9:00)sunday (9:00-10:00)
Current level
Children 4 years and older as well as adults*
prevnext( X )
Beginner White Belt (One class per week)$220.00CAD
Class schedule for the 11-week session, from October 5th to December 14th.*

Beginner White Belt (Two classes per week)$374.00CAD
Class schedule for the 11-week session, from October 5th to December 14th.*

Beginner White Belt (Four classes per week) $572.00CAD
Class schedule for the 11-week session, from October 5th to December 14th.*

For the 34-week in a year (Two classes per week) $1,020.00CAD
Class schedule for the 11-week session, from October 5th to May 17th.*

For the 34-week in a year (Four classes per week) $2,720.00CAD
Class schedule for the 11-week session, from October 5th to May 17th.*

Intermediate: Orange to Green Belt (One class per week)$275.00CAD
Class schedule for the 11-week session, from October 5th to December 14th.*

Intermediate: Orange to Green Belt ( Two class per week)$484.00CAD
Class schedule for the 11-week session, from October 5th to December 14th.*

For the 34-week year (Two classes per week) $1,360.00CAD
Class schedule for the 11-week session, from October 5th to May 17th.*

Advanced: Green Belt and above (Two classes per week) $660.00CAD
Class schedule for the 11-week session, from October 5th to December 14th.*

Advanced: Green Belt and above (34-week year two classes per week) $1,700.00CAD
Class schedule for the 11-week session, from October 5th to May 17th.*

Total $0.00CAD
Contactless payment method preferred

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

11-week session: Half of the payment is required by October 5th and the other half by December 5th For the year (34 weeks): Half of the payment is required by October 5th and the other half by May 5th.

Shitoryu Karate Canada affiliation fee 25$ 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

Cash - please make payment at beginning of classOnline payment - Interact- dynamiquekarateacademy@gmail.com
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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I authorize the publication of photos and videos in which me and my children appears(in the case of a minor child)
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DYNAMIC KARATE ACADEMY Registration Form