AU Membership

I. Customer Information

Name*

First NameLast Name

Kid's Name

First NameLast Name

Date of Birth*

MonthDayYear

Contact Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Emergency Contact*

First NameLast Name

Emergency Contact's Number*

Area CodePhone Number

II. Term

1. Membership*

MonthlyPer-class

2. Monthly Program Price*

Kids ($100)Adults ($125)

Monthly payment is due on the first of each month. Customer will pay by automatic payments, which will be set up by ARTS UNITED CAPOEIRA using THE SQUARE
Any account more than 5 days past due will be charged a $10.00 late fee.
Any return payment will be assessed a $25.00 fee.
Any unsuccessful scheduled electronic transaction is subject to a $10.00 processing fee.
The phrase “SQ Arts United Capoeira” will appear on your credit or debit card statement.
The CUSTOMER will receive a text message and/or an email with the automatic payment confirmation number from “THE SQUARE” every first of the month.

3. Registration Fee: $85

This includes the uniform (shirt, abada and crua cordao)

4. Starting Date

MonthDayYear

5. CANCELATION NOTICE: 30 DAYS (a written cancellation notice is required; please refer to payment agreement)

6. BILLING FREQUENCY: EVERY FIRST OF THE MONTH. (If member joins in after the first of the month, then the month’s fee will be calculated accordingly, succeeding months will be billed on the regular billing cycle.)

III. BILLING METHOD:

Form of Payment*

Credit CardCheckCash

Type of Credit Card*

VisaMaster CardAmex

Name on the Credit Card

First NameLast Name

Credit/Debit Card Number

Expiration Date

Security Code

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

ARTS UNITED CAPOEIRA Payment Agreement

This agreement is between Arts United Capoeira and Customer in relation to Business. The phrase “SQ Arts United Capoeira” (SQUARE) will appear on your credit or debit card statement. Monthly payment is due every first of the month. Any account more than 5 days past due will be charged a $10.00 late fee. Any return payment will be assessed a $25.00 fee. Any unsuccessful scheduled electronic transaction is subject to a $10.00 processing fee. Arts United Capoeira is not responsible for any bank fees incurred by Customer. Arts United Capoeira has the right to charge monthly payments on the first of each month to the credit or debit card on record. Arts United Capoeira has the right to resubmit returned or declined items (plus applicable fees) without prior notice to the credit/debit card on record. If Customer wishes to cancel this Agreement, the Customer must provide a written cancellation notice to Arts United Capoeira 30 days prior to the next billing cycle. If the Customer cancels this agreement, any initial fees or down payments will not be refundable and Arts United Capoeira will be entitle to the total agreement price.

BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ ALL OF THE TERMS, CONDITIONS AND STATEMENTS OF THIS AGREEMENT AND UNDERSTAND, ACCEPT AND AGREE TO ALL MADE HEREIN.

Signature*

Signature Date

MonthDayYear

Membership Application

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