Timber Trace Registration Form

MA Club Registration

Please complete the form below to sign up
Today's Date
Student Name*

First NameLast Name
Student's Grade*
Teacher's Name*
Birth Date *

MonthDayYear
Parent or Legal Guardian*

First NameLast Name
Phone Number:*
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
E-mail*
example@example.com
Have you (the student) have prior martial arts experience?

YesNo
What Style
What belt level did you achieve?
Are you a Certified Kukkiwon Black Belt?

YesNo
What Dan Are You?
What is your Kukkiwon Dan Number
Do you have any medical history or conditions that could affect your ability to participate in contact sports? *

NoYes (Please enter details)
Medical Conditions
Where did you hear about us?

Online Search (Google, Bing, Yahoo)A Friend or colleagueLocal Activities ListingNews ArticleOther
Payment Policy

*QUARTERLY PAYMENTS AND AUTOMATIC BILLING (ACH) POLICY: All ACH students are enrolled in automatic monthly billing upon joining American Martial Arts Center (AMAC).
1. By signing this Membership Agreement below, you authorize AMAC, and its successors and assigns, to automatically bill your Checking or Savings account, and/or collect quarterly payments on the 28th day of each month or quarter (Automatic Payment Date) for the monthly or quarterly cost of annual membership and any additional fees in association with testing, uniforms, equipment or cancellation, as further described in the Cancellation Policy and Terms and Conditions below.
2. A $25 Service Fee will be assessed for each returned or rejected automatic payment or quarterly payment attempt.
3. Any changes to your account information must be made in writing and received by AMAC 30 days prior to the next Automatic Payment Date in order for changes to take effect without being subject to a possible Service Fee.
4. The Initial Membership Term is for one year (12 Months) from the date of this signed Membership Agreement and will automatically renew for additional one-year terms unless written notification is received in accordance with the Cancellation Policy.
5. AMAC reserves the right to adjust the annual cost of membership following the end of the Initial Membership Term and any time thereafter having given 30 days prior notice.
6. ACH PAYMENTS. I understand that because this is an electronic transaction, these funds may be withdrawn from my account each month on or before the Automatic Payment Date in accordance with the provisions of U.S. law, and I am responsible for ensuring sufficient funds are available and will not dispute the recurring billing with my bank; so long as the transaction corresponds with the terms outlined in this agreement.
7. CANCELLATION POLICY: If you wish to cancel this contract and stop automatic payments for any reason, including pandemics, natural disasters, unforeseen circumstances, loss of a job, or any other related or unrelated circumstance. You may cancel by sending an electronic notification to briancfleck@gmail.com or by mailing a written notice by certified or registered mail to 11800 S Gardens Dr, Palm Beach Gardens, Florida 33418. The notice must say that you do not wish to be bound by this contract and must be delivered or mailed 30 days before the end date of membership services.
8. If you cancel before the end date of the contract, AMAC may keep or collect an amount equal to the fair market value of the services or use of the facilities that you have already received; a cancellation fee, which currently is $99.00, will be automatically deducted in accordance with the Automatic Billing Policy. This fee is not in conjunction with services offered in exchange for membership and may not be combined with or used toward any membership privileges; it is a separate fee that will be collected only upon the cancellation of this agreement. PBSC members are exempt from any cancellation fees.
Please select and agree*

I have read and understand the payment policy
Choose Your Membership Plan*

$125.00 Monthly (2x per week)$85 Monthly (1x per week)
Payment Options *

ACH Monthly BillingCash (quarterly payments)
MEMBERSHIP RULES
1. Be on time!
2. Students are to place shoes, bags, or any other attire neatly by the entranceway.
3. Student uniforms are to be on before entering the Do-Jang (top included).
4. Belts should be tied around your waist without facing the
  instructors.
5. Always answer “yes sir” / “no sir” “yes ma’am” / “no ma’am” when speaking to a black belt/instructor.
6. All adult black belts shall be addressed as “Mr.” “Miss” or “Mrs.” followed by their first or last name. If you don’t know their name, ask. You may also address them as “sir” or “ma’am”
7. The Master Instructor shall be addressed as “Master Brian Or Master Fleck.”
8. When asked to line up, answer “yes sir” and quickly move to the position.
9. There is no talking in line, during drills, or in self-defense. If you have a question
  about the curriculum, ask. Do not carry on conversations during class time. This is a Martial Arts School, and you are here to train, not socialize. If you want to be social, do so before or after class, but not during class.
10. DO NOT ask when you can test for your next belt, or when the next testing is. The
  Master Instructor will invite you to test when He thinks you are ready.
11. Never leave the mat or the dojo without receiving permission from the instructor.
12. No food, drink, or chewing of gum is allowed on the mat.
13. No non-martial arts activity is to take place during class time. Show your instructor respect by paying attention. Save the conversation for after class.
14. Report all injuries to the instructor immediately. When arriving at class with an injury, the instructor must be notified prior to the start of class.
15. Shoes are NEVER to be worn on the mat.
16. Water bottles are permitted in designated areas. Water bottles are to have water or electrolyte beverages (like Gatorade) only.
17. Never come to class under the influence of drugs or alcohol.
18. Members are to keep their uniforms clean and in good repair.
19. Finger and toenails are to be kept clean and trimmed to a reasonable length to prevent injuries to training partners. Fingernails cannot have points, they must be rounded or have a straight edge.
20. No jewelry may be worn during class unless specifically approved by the instructor.
21. Members without uniforms should not have anything in their pockets. Judo involves pulling on the clothing, and whatever you wear could become torn.
22. No practicing of new techniques is allowed without the permission of the instructor. This includes techniques you learned on the internet, saw during a competition, or on a video.
23. Spills are to be cleaned immediately. Trash should be placed in the proper container.
24. Bullying is not tolerated in or out of the dojo. Members using their skills for bullying will not be allowed to return.
Please select and agree*

I have read, understood, and accepted the rules for membership.
Privacy Policy
Please select and agree*

I understand that occasionally, photos and videos from club competitions and practices will be used in promotional material for the club. I agree to allow my image or my child's image to be used for this purpose and that I will not be compensated. I also understand that once a promotional item has been produced, it is not possible to remove my image or my child's image from the production.
Please select and agree*

I understand that the club will never share my contact information for commercial purposes. I may, however, be contacted by the club managers about club announcements and information relevant to club membership.
Terms, Conditions, Disclaimer and Waiver of Liability
Student Waiver
1. In consideration for being permitted by My Traveling Dojo (MTD) and Timber Trace Elementary (TTE), to utilize its facilities and receive martial arts instruction, I, my heirs, and my legal representatives forever release, waive, discharge, and covenant not to hold MTD and/or TTE, its owners, directors, officers, instructors, operators, employees or agents liable in any way for any injury, death, or damage that may occur in connection with my use of its facilities.
  
  I understand and knowingly and voluntarily assume any and all of the inherent dangers and risks of martial arts instruction and training, and I am aware of the basic safety rules for such activities.
  
  I agree to use the facilities only in the manner and for the purpose for which the facilities are designed and shall be responsible for damage caused by me to the facilities or other members. I understand that I may elect not to participate in any technique or exercise demonstrated during any class. I understand MTD is not responsible for any injury that a member may incur due to the actions of another member in any class, practice, or demonstration. I understand MTD is not responsible for any loss or damage, including theft, to the property of its members or their guests.
  
  I assume responsibility for my own physical fitness and capability to use the facilities safely. I understand that a physician should be consulted before the commencement of any martial arts program.
  
  I recognize that there may be other risks that are not known to me or to others or not reasonably foreseeable at this time. I will immediately inform an instructor if I believe that anything is unsafe or beyond my capability and refuse to participate.
  
  I assume all of the foregoing risks and accept personal responsibility for any damages that may result from injury, permanent disability or death.
  
  I will enter martial arts training and/or competition entirely of my own free will and understand the importance of following the rules of training and competition.
  
  I certify that I am in good physical condition, and have no disease, injury or other condition that would impair my performance or physical and mental well-being during training practice and/or competition. If I have any injuries or illnesses that could affect my ability to participate, I will notify the club managers and coaches, and discuss the appropriateness of martial arts training with my doctor or my child's doctor.
  
  I grant permission in case of injury to have a doctor, nurse, athletic training or other emergency medical personnel provide me or my child with medical assistance or treatment for such injury. The cost of any treatment or hospitalization arising from injury during training or play shall not under any circumstance be paid by MTD, TTE, its affiliated organizations and governing bodies, their officers, instructors and personnel, other members of the organizations, participants, supervisors, coaches, sponsoring organizations or their agents.
  
  I understand that this program is a team effort between the student and MTD. In order to receive the full benefits of this program, I will fully support the School and the staff in their efforts to help me develop as a martial arts student.
  
  I understand that my advancement is based on American Martial Arts’ 5 Key Rating System, which is: Attendance, Effort, Knowledge of Curriculum, Fitness, and School Protocol (read the school handbook, at www.americanmartialartsjupiter.com).
  No amendment to this agreement will be effective unless it is agreed upon by MTD, attached separately in writing, and signed by both parties.
  
  By signing below, I am indicating that I have read, understand, and agree to this Membership Agreement, all the Terms and Conditions.
Please select and agree*

I have read, understood, and accept the disclaimer and liability waiver and sign it of my own free will
Signature of Parent or Legal Guardian*

Clear
Payment
IMPORTANT!
1. You must pay for classes and uniform/belt first then submit the form.
2. DONT FORGET to select the T-shirt size and belt size. They are default to (xs).
3. If you have any trouble, please contact Master Brian at, 561-741-4090.
First Payment and Uniform*
prevnext( X )
6 Classes Tuition 6 classes
$115.00



Student Uniform
$30.00 Shirt Size



Student BeltAll student's will receive a white belt. If you have prior training with a colored belt, please call Master Brian.
$15.00 Belt Size



Subtotal

$0.00

Tax

$0.00

Total

$0.00
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MA Club Registration

Privacy Policy

Terms, Conditions, Disclaimer and Waiver of Liability

Student Waiver

Payment

IMPORTANT!