UMAC Registration Form Please fill out and print TWO COPIES, then click the send button. Sign and either drop off or mail BOTH COPIES to: United Martial Arts Center 8809 Walking Stick Trail Raleigh, NC 27615 Make Check payable to USMAI, Inc. Thank You. NOTE: Your first month includes a free uniform valued at $45.00. REGISTRATION FORM Full Name E-mail Address City   State     Zip   Date   Date of Birth    Age   Sex    Male Female Home Phone   Work Phone    Employer Emergency Contact Contact Phone What are the top deciding factors in choosing The United Martial Arts Center? (Please check all that apply) Personal attention given in Class Quality of Instruction Reputation Curriculum Location Facility Atmosphere Price of Program A Fun and Different Activity Other If other, please comment: How would you like to benefit from our classes? (Please check all that apply) Improve Coordination More Self-Discipline Increase Confidence Learn Self Defense Skills Respect for Self and Others Temper Control Lose Weight Better School Grades Positive Mental Attitude Other If other, please comment: How did you hear about our program? What are you currently involved in for extra curricular activities? Do you have any health-related issues or history that would effect your participation in our program? Check if you can answer 'Yes' to these following questions. Will you be living in the area for at least one year? Can you take your lessons on an average of twice per week? Have you read and agree to the student creed? Do you have a place to practice what you have learned in class? Are you willing to set your goals to develop your mental and physical fitness? Select your service agreement: Karate Kid: Month to Month at $79.00 per month Future Masters: Introductory Lesson at $19.95 Future Masters: 1st Month at $199.00. Each Additional Month to Month at $169.00 per month THIS PROGRAM INCLUDES: QUICK START SESSION EXTRA HELP SESSIONS CERTFICATES* BELTS* EXAMS* MAKE UP LESSONS FREE GUEST PASSES BLACK BELT UPDATE NO HIDDEN OR EXTRA COSTS THIS PROGRAM DOES NOT INCLUDE: STUDENT MANUAL $20.00 (not needed until after 30 day trial: curriculum, history, requirements, and more) SAFETY EQUIPMENT $243.94 (not required until yellow belt or after approximately 6 months) THE FUTURE MASTERS CLASS TAUGHT BY MASTER ADAM SCHAINBLATT * No extra charges for these items Under Black Belt, 1st Degree Black Belt and higher do have separate fees for Belts, Exams, and Certification Agreement starting date: NO RISK 100% SATISFACTION GUARANTEE - Upon enrollment member may cancel his/her membership for any reason at any time with a 30 day written notice. NOTE: All payments must be current, a cancellation fee of $10.00 will be charged & any regularly future scheduled payment within 30 days of written notice must be paid in full. In the event that the Enrollee cancels his/her membership & wishes to re-enroll, a new enrollment agreement will be required with the current prices. 1. Each annual anniversary of your membership there will be an increase of 5% of the proceeding years payments. 2. UMAC has the right to cancel classes on National Holidays, bad weather days, and the last two weeks of the year. 3. Uniforms, seminars, tournaments, etc. are separate fees not included in the terms of this Agreement Note a late charge of $10.00, or 1.5-% daily or 18% APR, whichever is greater, will be assessed if the payment is ten days past due. No course certificate will be issued unless all Payments are current. Family discounts are only applicable if the first family members account remains active, current and in good standing. Enrollee agrees to abide by the rules and regulations governing the conduct and operation of instruction sessions, students, and observers. The hours of operation and class times may be changed at the discretion of the UMAC. The UMAC reserves the right to revoke or terminate any membership. 4. Enrollee’s Certification of Fitness and Waiver of UMAC's and /or USMAI, Inc., Liability for Personal Injury. By signing this form, the Enrollee certifies that He or She is in good health and fitness. Enrollee agrees and recognizes that all exercises and /or courses are undertaken at the Enrollee's own risk. The Enrollee understands the procedures and exercises involved in instruction and participation as explained to him/her by an assistant or employee of the UMAC and /or USMAI, Inc. The Enrollee understands that there is a risk of personal injury involved in the course of instruction and with this knowledge waives his or her right to compensation for any and all loss arising hereunder and agrees to indemnify and save harmless the UMAC, USMAI, Inc., it's owners, agents, instructors, other customers and members, guests, and employee’s from any and all liability or damages resulting from either personal injury or theft or loss of personal property whether or not due to the negligence of the Operator, and any and all losses caused by accident or injury to the Enrollee, or to third persons, who may be Enrollees of the UMAC, in the event that either the Enrollee or said third person is injured in any way during the performance and execution of exercises. The owner of the UMAC, USMAI, Inc., and its agents and employees shall not be responsible for such personal injuries or for damaged, lost or stolen articles, inside or outside facility. 5. Enrollee understands that UMAC does not guarantee Belt Rank Promotions. Enrollee understands that it is his or her responsibility to attend instructional sessions. Enrollee understands that the monthly fee paid for membership is due and payable according to the terms of the membership, whether or not Enrollee chooses to attend instructional sessions provided by UMAC. 6. Authorization to Use Likeness. I, the Enrollee or Member irrevocably authorize the UMAC, its successors and assigns, and those acting under its authority, to copyright, use, publish for art, advertising, trade, or any other lawful purpose whatsoever, photographic portraits, pictures or videotapes of Enrollee(s), in which Enrollee(s) may be included in whole or in part. 7. Cancellation and Refunds. In addition to the above NO RISK 100% SATISFACTION GUARANTEE, upon enrollment the Enrollee has the right to cancel and request a refund of his/her membership until midnight of the third business day after the member enrolls. Cancellation occurs when the Enrollee gives written notice of cancellation to the Seller at either of the following addresses: 1121 Falls River Ave., Ste 103, Raleigh, NC 27614. Notice of cancellation need not take a particular form and is sufficient if it indicates by any form of written expression the intention of the Enrollee to cancel his/her membership. For purposes of clarity, business days are all days other than Saturdays, Sundays, holidays, and days on which the Seller's facility is not open to the Enrollee. Enrollee will receive said refund within 30 days of written notification, less the cost of any merchandise that was either not returned, used, soiled or damaged. No refunds are given for cancellation requests that are given or postmarked after midnight of the third business day after the member enrolls or after enrollee has participated in any class or for any equipment or clothing that has been worn or used. 8. By signing this Agreement, Buyer certifies that he/she has received a copy of this Agreement and has read the entire Agreement (including the terms on the back of this page) and agrees to bound by its terms. > Signature (Seal) ______________________________________ Date: Accepted By: (Seal) ____________________________________ Date: ANY HOLDER OF THIS CONSUMER CREDIT CONTRACT IS SUBJECT TO ALL CLAIMS and DEFENSES WHICH THE DEBTOR COULD ASSERT AGAINST THE SELLER OF GOODS OR SERVICES OBTAINED PURSUANT HERE - TO OR WITH THE PROCEEDS HEREOF. RECOVERY HEREUNDER BY THE DEBTOR SHALL NOT EXCEED AMOUNTS PAID BY THE DEBTOR HEREUNDER. Please print TWO COPIES before you click send. Sign and mail BOTH printed copies to the following address. Thank You. Adam Schainblatt's United Martial Arts Center 8809 Walking Stick Trail Raleigh, NC 27615