Client Enrollment Form

Client Enrollment Form

Please complete all information including your personal information and the class/classes you are enrolling/enrolled in.
Your information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your membership
Membership Level
As a Silver member, you can enrol in 1 class per week as your 'home base'. Check one class to nominate as your 'home base' class.
As a Gold member, you can enrol in 2 class per week as your 'home base'. Check two classes to nominate as your 'home base' class.
As a Platinum member, you can enrol in 3 classes per week as your 'home base'. Check three classes to nominate as your 'home base' class.
As a Diamond member, you can enrol in 4 classes per week as your 'home base'. Check four classes to nominate as your 'home base' class.
As an Ultimate member, you can enrol in 5 classes per week as your 'home base'. Check five classes to nominate as your 'home base' class.

You can still attend unlimited classes, but you can only enrol in a maximum of five, in order to keep all classes financially viable.
Your enrolment
Day of classes (if enrolling on more than one day, check all days you will attend)
You are enrolling for:
Monday classes
Tuesday classes
Wednesday Classes
Thursday Classes
Friday Classes
Saturday Classes
Should be Empty:

Client Enrollment Form

Your information

Your membership

Your enrolment