ACA - Falcon 1 Karate Membership Form

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Office: 205-758-2242
Email: senseimichael89@gmail.com
Karate Lessons at Your School

This form uses secure technology to collect and store your information.

Mailing Address:

Team Lee Athletics LLC
PO Box 70323
Tuscaloosa, AL 35407

Parents Information

School *

First Name *

Last Name *

Contact Information

Present Mailing Address *

City *

State *

Zip Code *

Phone

Father Cell *

Mother Cell *

Does Cell Receive texts? *

Yes

Email Address *

Employer

Occupation

Work Phone

1st Student Information

Enter the information below for your student. If registering more than two students please fill out multiple forms.

1st Student Name *

1st Student Date of Birth *

YYYY

2nd Student Information

Enter the information below for your student. If registering more than two students please fill out multiple forms.

2nd Student Name

2nd Student Date of Birth

YYYY

Please note, for the student to receive maximum physical and mental benefits from this program requires a commitment of time. It takes repetition of physical moves and positive mental attitudes for them to become automatic reflexes. By filling out the form below, you are giving permission for your child/children to participate in a Team Lee Athletics L.L.C. program for the school year. You also release Team Lee Athletics L.L.C and any/all of its representatives from any/all liability for any and all possible injuries/accidents/illness that may occur during the child/children's performance, training, or association with, and for, any of the Team Lee Athletics L.L.C. programs.

Special information about Student

Back up contact name

Back up contact phone

Lesson Plan weekly - 45-minute lessons during the school year (September - May).

Class Tuition: $639 + $89 Registration fee = $728 if paid in full, or 9 installments of $71 post-dated checks September through May, or 9 installments of $73.13* by account bank draft or credit/debit card.

Registration Fee $89

Includes:
Annual Membership fee $30 Free Falcon 1 Athletic Tshirt!
Uniform $60 Value
Patches $15 Value

+ 1st Installment of $71

TOTAL DUE AT REGISTRATION = $160

* All fees are non-refundable.

Billing Consent *

20% Tuition Discount for 2nd Child

I allow to be billed $73.13* by Team Lee's automatic draft on the 1st of each month. Starting Oct. 1

I allow to be billed $131.63* for two children by Team Lee's automatic draft on the 1st of each month. Starting Oct. 1

I will pay Tuition in Full via check mailed to the above mailing address with my child's name on the check or via Paypal by following the link in my confirmation email.

Required

*3% draft/finance fee has been applied if tuition is paid in monthly installments. 3% convenience fee applied for payments made via Paypal

If Paying by Checking Account Draft (Preferred)

Please provide checking account information below if paying by checking account draft

Billing Account Information

(Make checks out to FALCON 1 DEFENSE)

Name as shown on account

Checking Account

Routing Number

Account Number

If Paying by Credit Card

Please provide credit card information below if paying by credit card instead of checking draft.

Credit Card Information

Credit Card Number

Expiration Date

YYYY

Zip Code

Acknowledgement of Payment Required to Complete Registration *

I acknowledge that I understand that my child's registration is not complete until first payment of $160 is received. I understand that an email will be sent to me with a payment link to pay by installments or pay in full once I submit this registration.

Required

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