Basic Membership Enrollment Form

Membership Enrollment
$150 Monthly Tuition or Six Months Special for $675
Member's Name*
First NameLast Name
Birth Date
MonthDayYear
Gender
Address*
Street Address
Street Address Line 2
CityState
Zip Code
Student E-mail*
example@example.com
Mobile Number*
Your Course*

Course Price*

Full Program MembershipTuition runs automatically every month on the day of enrollment (if you sign up on the 7th then it will be on the 7th of every month). We do not use contracts so you can cancel at anytime.

$150.00Class T-Shirt Size

6 Months SpecialGet 25% off by paying for six months at a time & SAVE $225

$675.001st Member T-Shirt

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

In consideration for my attendance and participation at Chesapeake Kung Fu/Tai Chi and Virginia Beach Kung Fu/Tai Chi, I, the student, acknowledge the existence of certain inherent risks in this type of training and hereby agree to assume all risks. I further relieve Chesapeake Kung Fu/Tai Chi and Virginia Beach Kung Fu/Tai Chi, and fellow students, from any liability resulting from personal injury or loss of personal belongings. I also state that I am physically fit to take the prescribed course of instruction and do so of my own free will. I will seek my doctor's approval if I have any physical concerns before participating in this type of training course*
I Agree to the Terms & Conditions above
Yours for Better Health, Greater Strength and Competent Skills.
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