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Hello and Welcome to the sign-up process. Signing up is a very easy process, this form will guide you through it. During the process you will be asked for your height, this is to determine your Gi size. Your Gi and your Federation membership are included in the price. Signing up usually take 3 1/2 minutes on average so lets get started. The Way our contract billing system works is each student needs to fill out this form, so if there are three students from the same household each one will need a separate contract filled out.

Buyers Info:
First Name: Last Name:
DOB: Gender:
Address: Email:
City: Zip:
Phone: State:
Driver Lic# Issued State:
Student Data:  check box if buyer and student are the same
First Name: Last Name:
Gender: DOB:
Address: Zip:
City: State:
Phone: Dojo Location:
Emergency Contact Information:
First Name: Last Name:
Phone Number: Relationship:
   
First Name: Last Name:
Phone Number: Relationship:
   
First Name: Last Name:
Phone Number: Relationship:

Class Fees:

Monthly Class Fees

 

Monthly

(1- night per week)

Monthly

(2-nights per week)

3- Month

(1 -night per week)

save $20.00

3- Month

(2-nights per week)

save $25.00

1st  Adult

$70.00

$90.00

$190.00

$245.00

2nd and  3rd  Adult

$60.00

$75.00

$180.00

$225.00
   

Monthly Class Fees

 

Monthly

(1- night per week)

Monthly

(2-nights per week)

3- Month

(1 -night per week)

save $20.00

3- Month

(2-nights per week)

save $25.00

1st Youth

60.00

$75.00

$160.00

$200.00

2nd and 3rd  Youth

$55.00

$70.00

$160.00

$200.00
   

Checking Account:

 		Savings Account:
Bank Name: Bank Name:
City: City:
ST: ST:
 Zip:  Zip:

?

 ABA Routing Number: Routing Number:
Account Number: Account Number:

Clothing:

  
 

Size

Imperial (in, lb)

Price

000

   3ft 7in - 3ft 10in Included in price of signup

00

   3ft 11in - 4ft 2in Included in price of signup

0

   4ft 3in - 4ft 6in Included in price of signup

1

   4ft 7in - 4ft 10in Included in price of signup

2

   4ft 11in - 5ft 2in Included in price of signup

3

   5ft 3in - 5ft 6in Included in price of signup

4

   5ft 7in - 5ft 10in Included in price of signup

5

   5ft 11in - 6ft 2in Included in price of signup

6

   6ft 3in - 6ft 6in Included in price of signup

7

   6ft 7in - 6ft 10in Included in price of signup
 

Estimated Gi Size:
Belt Color:
I authorize my bank to debit my account as identified above to the terms stated here.  This authorization shall remain in effect until Heartland payment Systems and the bank receive written notification from me of intent to terminate at such time and such manner as to afford Heartland Payment Systems and the bank reasonable opportunity to act (Minimum 30 days)

I understand that if the total amount owed to heartland Payment Systems is increased, I authorize this plan to continue as long as the payment amount remains unchanged until the amount owed Heartland Payment Systems is paid off, or unless the plan is terminated earlier by me as above.  I understand any added amounts can be applied for with a new authorization form.

All other changes such as payment amount, frequency, bank account number change, will require a new payment Authorization form to be filled out and submitted to Maine Traditional Karate 15 days prior to any change being implemented.  I understand that this payment plan may be cancelled by Heartland Payment Systems or Maine Traditional Karate due to NSF (Non-Sufficient Funds).  I will be liable to pay an NSF fee of $25.00(or the amount allowable by law).

I represent and warrant that i am authorized to execute this payment authorization for the purpose of implementing this payment plan.  I idemnify and hold Heartland Payment Systems, ht e bank, and Maine Traditional Karate harmless from damage, loss or claim resulting from all authorized actions hereunder.

Membership Benefits

 

·        Direct link to Hanshi Kise ( with all rights & privileges) 

·        Open invitations to all OSMKKF events, i.e. Hanshi’s annual visit,

all dojo workouts with Shihan Lazarus, 8th Dan, tournaments, and

seminars.  (note: does not include event fees or gratuities)

 

Special Notes:

 

Contract Length:

 

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