Please choose your fitness program: * Summer Special Little Dragons $90 Summer Special Junior Dragons $149 Summer Special Senior Dragons and Adults $170 Summer Special Yoga and Tai Chi $160 Lil Souls Yoga Workshop $125 Kung Fu Adults (Ages 15 - and up) $85/month Kung Fu Senior Dragons (Ages 8 - 14) $85/month Kung Fu Junior Dragons (Ages 5 - 7) $70/month Kung Fu Little Dragons (Ages 3 - 4) $45/month Yoga & Tai Chi Membership 1 Year Contract/Auto Pay (includes both disciplines) $60/month Yoga & Tai Chi Membership (includes both disciplines) $80/month
Last: *
First: *
Gender: * Male Female
Age: *
Birthdate: *
Phone: *
E-Mail *
Parent Information: (if enrolling minor)
Fathers Name:
Father’s Phone:
Mothers Name:
Mother’s Phone:
Tuition Payment (Auto Pay)
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Payments automatically withdrawn on the first of every month by credit / debit card.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: Summer Special Little Dragons $90 Summer Special Junior Dragons $149 Summer Special Senior Dragons and Adults $170 Summer Special Yoga and Tai Chi $160 Lil Souls Yoga Workshop $125 Kung Fu Adults (Ages 15 - and up) $85/month Kung Fu Senior Dragons (Ages 8 - 14) $85/month Kung Fu Junior Dragons (Ages 5 - 7) $70/month Kung Fu Little Dragons (Ages 3 - 4) $45/month Yoga & Tai Chi Membership 1 Year Contract/Auto Pay (includes both disciplines) $60/month Yoga & Tai Chi Membership (includes both disciplines) $80/month
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.
2 + 0 = ? Please prove that you are human by solving the equation *