REGISTRATION: AFTER SCHOOL MARTIAL ARTS PROGRAM 14~15 US WHITE TIGER MARTIAL ARTS ACADEMY 5050-A Nicholson Lane, MD 20852 TEL)301-231-0880 STUDENT INFORMATION

REGISTRATION: AFTER SCHOOL MARTIAL ARTS PROGRAM 14~15

US WHITE TIGER MARTIAL ARTS ACADEMY 5050-A Nicholson Lane, MD 20852 TEL)301-231-0880

STUDENT INFORMATION

First Name(s) 1 ________________________ 2___________________________

3__________________________

Last Name(s) ________________________ __________________________ _______________________

Date of Birth 1. / / Age( ) M / F 2. / / Age( ) M / F 3. / / Age( ) M /

F

School(s) 1._________________ Grade ( ) 2._________________ Grade ( ) 3.______________ Grade

( )

Phone # (Home) _____________________ (Mom’s Cell) _____________________ (Dad’s Cell) ___________________

Address ______________________________________________ City ______________________ Zip

________________

Tuition Rate $380/month or $95/week /Non member student

$300/month or $75/week / Current membership student

$10/week Sibling Discount Extended Day: $25/day when school closed.

Registration Fee $80/student Paid Date____/____/____

Weeks Mon ~ Fri AmountPaid Date

Type Remarks Weeks Mon ~ Fri AmountPaid Date

Type Remarks

42 1 25-Aug 29-Aug 21 22 19-Jan 23-Jan

41 2 1-Sep 5-Sep 20 23 26-Jan 30-Jan

40 3 8-Sep 12-Sep 19 24 2-Feb 6-Feb

39 4 15-Sep 19-Sep 18 25 9-Feb 13-Feb

38 5 22-Sep 26-Sep 17 26 16-Feb 20-Feb

37 6 29-Sep 3-Oct 16 27 23-Feb 27-Feb

36 7 6-Oct 10-Oct 15 28 2-Mar 6-Mar

35 8 13-Oct 17-Oct 14 29 9-Mar 13-Mar

34 9 20-Oct 24-Oct 13 30 16-Mar 20-Mar

33 10 27-Oct 31-Nov 12 31 23-Mar 27-Mar

32 11 3-Nov 7-Nov 11 32 30-Mar 3-Apr

31 12 10-Nov 14-Nov 10 33 6-Apr 10-Apr Spring Break

30 13 17-Nov 21-Nov 12 31 13-Apr 17-Apr

29 14 24-Nov 28-Nov 8 35 20-Apr 24-Apr

28 15 1-Dec 5-Dec 7 36 27-Apr 1-May

27 16 8-Dec 12-Dec 6 37 4-May 8-May

26 17 15-Dec 19-Dec 5 38 11-May 15-May

25 18 22-Dec 26-Dec 4 39 18-May 22-May

24 19 29-Dec 2-Jan Winter Break 3 40 25-May 29-May

23 20 5-Jan 9-Jan 2 41 1-Jun 5-Jun

22 21 12-Jan 16-Jan 1 42 8-Jun 12-Jun

Unpaid balance is due in weekly installments which will be automatically debited from your account on Monday of each week registered. First payment due or deduction beginning on ______/______/______ (Monday) and continuing for _________ consecutive times in the amount of $____________. By singing below, I authorize US White Tiger Martial Arts Inc. and it’s affiliates to initiate and execute a debit from the card account I have indicated.

VISA Master Card

Credit Card Account # : ____ Exp. Date:______/________

Authorized Signature (Account Holder) Date: _____/______/______

Space is reserved for your child AFTER registration fee and tuition deposit is paid. No refunds on this paymentBy signing below, I certify that I’ve received a completed copy of this agreement and the program terms & conditions 1/2, 2/2 and agree to all terms & conditions and rules & regulations of this program.

Parent or Legal Guardian’s Signature : ________________________________ Date : ______________

STUDENT HEALTH HISTORY

Child’s name : .

The following information is required for a student to be admitted to program :

STUDENT IMMUNIZATION INFORMATION

All students must be current on all immunizations, see www.EDCP.org (Immunization)

1. Provide date (month and year) of student’s last tetanus (or DTP) shot : .

2. Is the student currently enrolled in a Maryland school, public or private ?

YES, provide name of Maryland school : .

No, provide a copy of immunizations confirming that the child has received all immunizations as required by the Maryland DHMH Recommended Childhood immunization Schedule. See www.EDCP.org (Immunization) for information

3. Is the student exempt from any immunization on medical or religious grounds?

YES, provide a signed copy of Maryland Department of Health and Mental Hygiene Immunization Certificate from either a licensed physician indicating that the immunization is medically contraindicated, or the parent or guardian indicating object to immunizations for religious reasons.

NOCONTACT INFORMATION : Parent or Legal Guardian : Phone : .

Emergency Contact Person : Phone : .

Student’s Physician : Phone : .

HEALTH INFORMATION : Provide information on any medical conditions, psychological conditions, behavioral conditions, medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child’s program experience is positive :

Parent or Legal Guardian’s Signature : Date : .


AFTER SCHOOL MARTIAL ARTS PROGRAM


AFTER SCHOOL MARTIAL ARTS PROGRAM

Parent or Legal Guardian’s Signature : _____________________________ Date ______________

I hereby give my consent to any emergency facility and physician to administer necessary

treatment to my child (Name)

___________________________ in the event of an emergency at which time I cannot be

reached. I give consent for my child to be transported by ambulance if the situation warrants it.

Family Physician’s Name / Health Care Resource Telephone Number

Any Allergies or Special Needs :

.

Allergic to bee stings ? Yes No Not Sure (Check one)

Insurance Company covering child :

.

Policy No. Group No.

.

Release for Emergency Care & Notice to Parents

Name : .

Telephone No. : .

Name : .

Telephone No. : .

Emergency Contact Persons

To: Parent (s) of After School Martial Arts ProgramPlease understand that US White Tiger Martial Arts Academy is not a licensed day care or child care facility. We are a martial arts school that provides many benefits to our students and considers the safety and education of all students our number one priority. However, because we are not childcare professionals, our after school program should not be utilized for childcare needs. It is your responsibility to visit any after school facility and choose a program that meets your child’s interest.

US White Tiger Martial Arts Academy is located a Rockville/North Bethesda, Maryland.

Through our martial arts training, we teach many different mental and physical self-defense skills and build concentration. Through the philosophical aspect of our instruction, we are able to build more responsible, disciplined individuals, with a strong character while they learn how to be humble in daily life.

Our Head Master Kim, all has been trained in TaeKwonDo for more than 10 years and are certified TaeKwonDo black belts from Kukkiwon (The World TaeKwonDo Headquarter, which is the only organization who can certify TaeKwonDo black belts).

Please be advised that all students of US White Tiger Martial Arts Academy may come and go to and from all classes or the premises as necessary.

I have read the above disclaimer and accept it fully.

After School Martial Arts Program Terms and Conditions 1/2


I, as the Buyer, enter into this Agreement with US White Tiger Martial Arts Studio (hereinafter referred to as the “Studio” ), and do hereby agree, on behalf of myself, my children, and all persons who become entitled to use the facilities of the Studio by virtue of my program as follows :

WAIVER AND RELEASE I and my child(ren) fully recognize the risks of injury and/or illness inherent in participation in any fitness, martial arts or program, and we represent to the Studio that we have taken all reasonable steps to determine, and hereby warrant, that we are in good health and physically capable of participating in the programs and courses of instruction offered by the Studio. We acknowledge that the Studio shall make no, and shall have no responsibility to make and independent evaluation of our physical health or fitness. We understand and agree that all participation in any such fitness program or use of the Studio’s facilities or equipment on or off the premises of the Studio shall be at our own risk. I authorize the Studio to transport my child to required place and field trips. I understand and agree that the Studio will not be held liable for injuries, damages, etc., not caused by or resulting from negligence of the owners, operators, employees or persons in charge of such establishment out of or in connection with our participation in any program or course of instruction either on or off the premises of the Studio. We understand and agree that the Studio shall not be responsible for the conduct of other users of the Studio or it’s facilities or equipment or participants in the Studio’s off-premises programs, or for any injury or damage to property resulting from such conduct and we shall bring any action proceeding against the Studio for any payment compensation or claim for any injury or loss of property caused by any such user.

LOSS / DAMAGE / THEFT OF PROPERTY We understand and agree that neither the Studio, nor its officers, directors, agents, instructors or employees shall be responsible for any personal property which is damaged, lost, or stolen in or around the Studio or its facilities, or any of the Studio’s off-premises event.

RULES AND REGULATIONS I and my child(ren) agree to abide by the rules and regulations governing the conduct and operation of the facilities. We understand that the Studio has the right to alter or amend any and all rules and regulations, including those set forth in this Terms and Conditions, and we agree to abide by all such amended rules and regulations. We acknowledge that we have been provided with a copy of all current rules and regulations. We understand that the right to use the Studio’s facilities and programs may be suspended at any time, with or without cause.

PHOTOGRAPHS We hereby authorize the Studio and its agents, successors and assigns to photograph and/or video tape my or my child(ren) and/or our voice without restriction and to utilize such photographs/videos and/or voice transcriptions for any commercial purpose, including but not limited to the promotion and marketing of the Studio, and we agree that we shall not be entitled to receive any compensation whatsoever of any kind as a result of such us.

NOTICE OF CONSUMER RIGHTS 1. You may cancel this agreement without any penalty or further obligation within (3) business days from the date of this agreement. Notice of cancellation shall be in writing and mailed to US White Tiger Martial Arts ( = US WTMA) by registered or certified mail. 2. If you become disabled for at least three (2) weeks during the program terms and the disability is confirmed in writing by a physician, you have a right to an extension and/or termination of this agreement. 3. Relocation of School : Our school reserves the right to relocate or consolidate school locations within a ten (10) mile radius of the current location. We will make a good faith effort to replace with comfortable facilities, but we do not guarantee the same. 4. If the Studio is closed for a month or more, you are entitled to your choice of either an extension of the contract or prorated refund, except if the closing is not the fault of the facility, which case the choice remedy is the Studio’s. 5. This notice of Consumer’s Rights is an integral part of the Application and Agreement for Program.

BAD CHECK AND DECLINED PAYMENT PENALTY A $30 service charge for any returned check or declined Automatic Credit Card payment will be assessed.

LATE PAYMENT PENALTY AND/OR FAILURE OF PAYMENT If payment is not received on time, or payment is returned, a $20.00 late fee per student will be assessed up to the first 3 business days then an additional $5.00 for each day thereafter. If the payment is not received within two weeks (14 days), US WTMA will turn over the dishonored payment, or nonpayment, and all other available information related to this balance to the collection company. If the unpaid balance is forwarded to the collection company, US WTMA will not seek restitution from the payer. The funds will be remitted to the US WTMA by the collection company. Furthermore, your child will no longer be able to participate in the program.

MISSED DAYS DUE TO ILLNESS, VACATION, ETC. The studio does not compensate tuition or fee for student’s absence. Full tuition and fee are due regardless of absence.

CHANGE / MODIFY PROGRAM Any modification or cancellation to this agreement requires two (2) weeks written notice to US WTMA. A $50 cancellation/modification fee will be charged per each written request.

LATE PICK UP PENALTY Our After School Martial Arts Program ends between 5:00 PM ~ 5:30 PM. We encourage parents to pick-up by 6:00 PM. A late pick-up fee will be assessed at $5 per every 10 minutes after 6:15 PM. Excessive late pick-ups will result in your child’s discontinuation of the program.

CURRENT MEMBER DISCOUNT Current member student discount valid ONLY through term of Membership Agreement. Any membership that expires during this program that is not renewed prior to the expiration, will be charged full weekly tuition for the remaining weeks scheduled.

After School Martial Arts Program Terms and Conditions 2/2


PROGRAM SCHEDULE Our program is set up to follow the Montgomery County Public School Schedule and Regulations for Elementary School (1st ~ 5th Grade) Students.

HALF DAY PROGRAM If your school district schedules an early dismissal, our buses will transport early and program or activities will be expanded in order to accommodate for the extra time at no additional tuition charge. However, a minimal field trip fee may apply.

EXTENDED DAY PROGRAM There may be extended day programs from (8:00 AM~5:00 PM) due to school closures, excluding Federal Holidays, Thanksgiving and Christmas. Extended day program fee is $20.00/student and additional field trip fee may apply separately.

WINTER / SPRING BREAK SCHEDULE After school Martial Arts Program is closed during Winter / Spring break. However, we may offer an all day Winter / Spring Break Camp Program.

INCLEMENT WEATHER SCHEDULE The Program will be closed in the event that Baltimore County public school systems close school for the day due to inclement weather. In case schools dismiss early due to inclement weather, we may open the program and try to pick the students up from the school early at no additional charge. However, US WTMA will close the number of hours schools dismissed early. For example, if schools dismiss 2 hours early, US WTMA will lose at 4 p.m. After School Martial Arts Program activities will be expanded to accommodate the extended time. If the Baltimore County Public schools are not opening due to inclement weather, our program is also closed.

TRANSPORTATION Students will be transported to and/or from their respective schools at a specific time. Therefore, it is imperative that each student be ready to board the transport van at the prescribed time. Drivers cannot be held accountable for students who are not at their pick-up point at their designated time. Our pick up schedule has been carefully planned to handle student pick-ups in a timely sequential fashion. Drivers will use careful discretion and attempt to be reasonable in grace periods for waiting. However, we cannot guarantee a specific waiting period will be allocated in waiting for students. Simply put, if students are to be picked-up at 3:30 PM they must be there at that time. Schools will be informed of this pick-up.

Student will be required, as by law, to wear their seatbelts at all times while being transported. Any student who violates this policy continuously, will be excused from our program.

MARTIAL ARTS CLASS As part of our After School program, students will participate in our martial arts program. Classes will be held 2 times a week. Our program has a natural order of progression through belt promotions. Students enter our program as white belt and attain promotions through the instruction process. It normally takes a student about 1 ~ 3 months to be eligible for belt promotion testing. Additionally, there is a testing fee that is due prior to the scheduled test date. Each student will be notified when they are candidates for testing. Sparring equipment (Safety Gear) is recommended once they reach yellow belt and required when they reach Super Blue belt to take a sparring lesson.

HOMEWORK ASSIGNMENT Our objective through our After School Program is to provide an environment, whereby students can learn and develop through their own academic curriculum and our martial arts program. We will make every effort to monitor and check all homework, but we are limited to the extent as to what homework assignments exists as communicated by the student. If a student does not cooperate with our staff, then we cannot be held responsible for the lack of completion of homework.

Our objective is to help the student complete his/her homework with the encouragement and support of our staff. We provide the conditions for which the child can achieve. We cannot be placed in positions of responsibilities for lack of completion of homework on the part of the program. A student not wishing to complete their homework or not able to understand their homework assignments, requires a different approach and is not within the scope of our program. We will notify you in the event that the student seems disinterested in homework, or is uncooperative in our program

NOTIFICATION FOR ABSENCE Notify us as soon as possible in the event that your child is sick from school that day or goes home early from school. If you don’t, we have to wait for children who are not at school. Our voice-mail system operates 24 hours a day 7 days a week. Call (301) 231-0880 and leave a message

TIME-OUT / DISMISSAL / TERMINATION OF ENROLLMENT Consequences for failure to observe the above rules and guidelines vary according to the nature of the infraction, but can include loss of privileges, “time-out”, or dismissal for the program. In certain circumstances, it may be necessary for the Director to decide to discontinue a child’s enrollment. Such a decision would be based on whether it is in the best interest of that child, the other children in the program and/or the overall operation of the program. Every effort will be made to correct a problematic situation before final decision is made. Termination of enrollment may be the result of, but not necessarily limited to, the following : Non-payment of tuition or fees, consistent late pick-ups, Studio’s inability to meet child’s needs, disruptive or dangerous behavior, abuse of fellow classmates, staff or property, etc..

Documents

REGISTRATION: AFTER SCHOOL MARTIAL ARTS PROGRAM 14~15 US WHITE TIGER MARTIAL ARTS ACADEMY 5050-A Nicholson Lane, MD 20852 TEL)301-231-0880 STUDENT INFORMATION