Registration

2021 Registration

Please contact us to schedule your free trial class before registering.
If registering more than one family member, please list Student #1 as the member with the highest membership rate.

Adding a family member to your existing membership? Click here.

* Indicates required field

Student #1 Name *

Student #1 Birthdate *

Student #1 Class Placement *

Ages 4-7: Little Warriors Ages 8-13: Young Dragons Ages 14+: Striking and/or Grappling

CONTRACT & RATES - select monthly rate from one of the drop down menus below

Select for ages 4-7: Little Warriors *

Select for ages 8+ *

Student #2 Name *

Student #2 Birthdate *

Student #2 Class Placement *

Ages 4-7: Little Warriors Ages 8-13: Young Dragons Ages 14+: Striking and/or Grappling

CONTRACT & RATES - select monthly rate from one of the drop down menus below

Select for ages 4-7: Little Warriors *

Select for ages 8+ *

Student #3 Name *

Student #3 Birthdate *

Student #3 Class Placement *

Ages 4-7: Little Warriors Ages 8-13: Young Dragons Ages 14+: Striking and/or Grappling

CONTRACT & RATES - select monthly rate from one of the drop down menus below

Select for ages 4-7: Little Warriors *

Select for ages 8+ *

Student #4 Name *

Student #4 Birthdate *

Student #4 Class Placement *

Ages 4-7: Little Warriors Ages 8-13: Young Dragons Ages 14+: Striking and/or Grappling

CONTRACT & RATES - select monthly rate from one of the drop down menus below

Select for ages 4-7: Little Warriors *

Select for ages 8+: *

Mother/Guardian (if under 18) *

Mother/Guardian Cell *

Father/Guardian (if under 18) *

Father/Guardian Cell *

Student Cell *

Home Phone *

Address

Street *

City *

State *

Zip Code *

Email (our primary communication with you) *

Emergency Contact Name & Relation *

Emergency Contact Phone Number *

Medical conditions or allergies? *

How did you hear about us / who referred you? *

SIGNED AGREEMENTS

LIABILITY
I agree not to hold Justin Press, Ephrata Martial Arts, and/or its teachers or associates responsible for any loss, injury, accident, liability, or sickness that might occur while I or my child are participating in classes, competitions, etc. I further state that all students listed on this registration are in good health and are not restricted from any physical activities such as martial arts, etc.

Please sign that you have read and agree to the above liability statements. *

FINANCIAL OBLIGATION
I have received and read the 2020 membership rates and understand that I am committed and liable for month to month (until a written notice is received for cancellation), one session, 6 months, or 12 months according to the commitment period I chose on this form, and that there is an early cancellation fee if I do not wish to fulfill the contract. I understand that for my registration to be complete I must pay the full or pro rated tuition for the current month.

I understand that monthly cash and check payments are only accepted under no contract, and that the homeschool session and 6 and 12 month contracts require an ACH (auto withdrawal) form to be completed unless if the amount for the full commitment period is paid in advance. (The ACH form can be acquired at our studio or by requesting through email)

Please sign that you have read and agree to the above financial obligation statements. *

GENERAL POLICIES
I agree to abide by the Ephrata Martial Arts code of ethics, dress code, and general policies.

(Please note that this includes not to distract the students and/or instructor(s) by talking or signaling to them during class or by making excessive noise, to take all phone calls outside, no rolling around/punching/etc while waiting for class, students keep a clean uniform and bow before stepping on/off the mats, no shoes on the training mats, and to wear shoes in the bathroom.)

Please sign that you have read and agree to the above statement. *

MEDIA RELEASE WAIVER
Ephrata Martial Arts is hereby granted permission to take photographs / video of any and all students to use in print or electronic publication. As student or legal guardian of student, I do understand that photos will eventually be removed from the website as pictures from the new classes / teams are put in its place. For internet safety, I understand that Ephrata Martial Arts will only use my name/my child’s name on the internet if I grant them permission (sign below). I also realize that my name/my child’s name may be mentioned in local newspapers should his or her photo be taken and used for that purpose. I am confident that photos of my student will be appropriate and of good taste. I hereby give Ephrata Martial Arts exclusive rights for all media use of my child’s image. This includes all print, non-theatrical, home video, CD-ROM, internet and any other electronic media, advertising, posters, social media and other promotional materials that may be created in the future. Ephrata Martial Arts also has the right to use and intertwine (with or without other materials) in full or portion any photographs / video footage taken as a result of participating in Ephrata Martial Arts classes and events. *This photo waiver applies to all classes, social events and public events that are associated with Ephrata Martial Arts when posting or using pictures/other media forms of the student:

Choose One: *

I DO also give permission to Ephrata Martial Arts to use my name/my child's first name and last initial if needed in any internet, social mdedia, print and/or media advertising. I DO NOT give permission to Ephrata Martial Arts to use my name/my child’s name (partial or full) in any Internet, social media, print and / or media advertising. I understand that I/my child may be asked to leave a specific area of an event where photos or interviews are being taken to ensure that they are not included in media. I also understand that Ephrata Martial Arts is not responsible for other parents and/or bystanders or the general public’s ability to post students' pictures and tag my student's name on the Internet or social media sites.

Signature (of Parent/Guardian if student is Under 18) Media Release Waiver *

REGISTRATION FINANCIAL AGREEMENT

With the submission of this form is due this month's tuition in part or in full depending on your start date. This payment will be *

No Contract: Paid monthly by cash or check and dropped off at the front desk No Contract: Paid monthly by auto withdrawal from checking account 6 & 12 Month Contracts: Paid monthly by auto withdrawal from checking account 6 & 12 Month Contracts: Paid by cash or check with one lump sum payment for the full length of contract

Coupon code / advertised special to be applied? *

Submit