Student Registration Form

Thank you for joining Phillips Martial Arts and Yoga Center. Please complete the New Student Registration Form below.

All information is kept strictly confidential. Only fully completed forms with payment will be accepted. An email confirming your enrollment will be sent to you shortly.

CURRENT SUMMER SPECIALS: Prepay 2 months and 3rd month is FREE!

Please choose your fitness program: *

Student Name:

Last: *

First: *

Gender: *

Age: *

Birthdate: *

Phone: *

E-Mail *

Parent Information: (if enrolling minor)

Fathers Name:

Father’s Phone:

Mothers Name:

Mother’s Phone:

Tuition Payment (Auto Pay)

Credit Card Information

Card Number *

Full Name On Card *

Card Expiration Date (mth/yr) *

Billing Address, City, State, Zipcode *

Security Code (on back of card) *

Payments automatically withdrawn on the first of every month by credit / debit card. INITIATION FEE WAIVED WITH AUTO PAY. If pro-ration applicable, pro-ration will appear on the next billing cycle. $20 No payment fee applied to account if Auto Pay payment does not process or is declined.

I give Phillips Martial Arts and Yoga Center (Robert Phillips, Phillips School of Kung Fu San Soo) permission to debit / charge the account provided within seven days from this online registration, and agree that the charge will reoccur on the first day of every month, and continue every month.

I want to enroll in automatic billing. *

Monthly Billing Amount:

Initials: *

Note: In Studio/Cash or Check Payment

“Direct Payment enrollment Option (tuition paid by cash or check each month): Enrollment must be completed on site. There is a $50 initiation fee, and first and last month tuition due at enrollment.”

Privacy and Consent: *

I have read the Client Privacy & Consent form before submitting this form. Submitting this client registration form indicates that I have read and agree to the terms and conditions of privacy and other conditions set forth.

5 + 2 = ?Please prove that you are human by solving the equation *

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