Karate Enrollment Form 2015

TERMS AND CONDITIONS
1. STUDENT FITNESS. By signing this agreement, Student represenis
warrants and ensures that he/she has had an opDorlunily to observe the
programs offered by PKSA Karate and that he/she is physically and mentally
the parties, whether written or orai. The invalidity or unenforceebility of any
provision hereof shall not affect the validity or enforceability of any other
provision. The waiver of any breach shall not constitute a waiver of any
abie to take classes offered by PKSA Karate in that program and/or any olhers
n which Student may participate. Student understands that he may not transfer
.r assrgn fiis membership
subsequent breach of this Agreement.
:.
UNAVAILABILITY. lf the PKSA Karaie facilities are unavailable for use for a
period in excess
of 30
consecutive days, the Student's program will be
extended for a period of time equal to the time of unavailabilrty, but no refund or
credit will be due the Student. Upon notice to the PKSA Karete location. the
Student may cancel this agreement if the PKSA Karate location facilites are
unavailable for more ihan 90 consecutive days. Wthin 30 days of receiDt of
such notice. the PKSA Karate location shall reFund to the Sludent the unused
pro-rata portion of lhe contract (cash) price. excluding any initiation fee, paid by
the Student. Notwithstanding the foregoing. the PKSA Karate localion may
close its facility on holidays for a period not exceeding five weeks per year for
necessary maintenance and other purposes without affecting scheduled
payments.
3. LIABILITY WAIVER AND RELEASE. The Student understands and agrees
7. ACCEPTANCE OF STUDENT. By signing, this Agreement, Student agrees
ro fullv and completely compy with all terms and conditions hereof and the
PKSA Karate rules and requlations. Failure to comply with PKSA Karate rules
and regulations is grounds for immediale suspension or termination of services
to the Student. Suspension or termination shall not entitle the Student to a
refund or credit for any amounts already pajd or cancel any unpaid balance
due. The tailure, or inability of Sludent to use the facilities. classes or servrces
of the PKSA Karate location for any reason. except as otherwise provided
herein does not relieve or suspend the Student's cbligation to make ail
payments required under this Agreement on a timely basls. no!- entitle the
Student to a refund or credit. PKSA Karale and those acting under its authonty
reserve the right to use photographs, Videotapes. artwork or other likenesses oi
the Student for marketing, trade, publishing or any other laMul
purpose.
Student understands and agrees lhat full payment of tuition is not a guarantee
or promise of advancement.
that strict observalon of PKSA Karate rules and regulations and the rules and
regulations relative to the service cr instruction provided. including the use of
protective equipment. is required. The Student understands and agrees that the
use ot the PKSA Karate facilities and the Students presence at the PKSA
Karate iacilii-v are at the sole risk of the Student. The Student understands and
agrees that the seruices or instruction provided may involve skills and training
which include violent and sudden movements and that in connection with the
training and instruction, there may be physical contacl between instructors and
Students and between and among the Students and that such contact may
result in personai injury to the Student, despite precautions taken to avoid such
8. DEATH OR DISABILITY. lf Studeni becomes disabled. the Student may
extend the term of the Agrcement. at no additional cost, by written notice to
PKSA Karate location. for a period of tirne equal io the duration of the Student's
short- term disabrlity, verified by a physician, which precludes the Student from
using any of PKSA Karate facilrties for a period of less than six (6) consecutive
months. The Student or his/her legal representative may cancel the Agreement
if the Student dies or becomes permanently disabled. Permanent disability is a
drsabilrty, verified by a physieian. which preclucies ihe Student from using any of
PKSA Karate facilities for a period in excess of six (6) consecutive months.
injunes. Student hereby consents
9. RELOCATION. Upon notice to the PKSA Karale location and satisfactory
to engage in such contact as may
be
necessary or required by Student's participation.
of him/hersef and anyone cJaiming by or through the
Student. hereby holds harmless, reieases and forever discharges PKSA Karate,
Key Web Enterprises, DBA PKSA.com, its ofticers, directcrs- employees,
agents and representatives and the PKSA Karate location and its instructors.
agents. employees, operators and authorized rep!'es€ntatives from any liability,
claim, loss. including loss of property. damage. personal injury, or expense
incurred by the Student and arising from the Student's execution of thjs
Agreement, payment processing, participation in any program otfereci by PKSA
Karate. including. but not limited io, any injury or damage caused by the
negligence or willful misconduct of PKSA Karate, Key Web Enterprises DBA
PKSA.com. the PKSA Karate iocation, its instructors. Students, agents,
employees, operators, or authorized representatives. The Student specficaily
understands anC agrees that helshe is assumlng the risk of any and all injuries
that heishe mav suffer or incur as a result of his/her execuiion of this agreement
and participation in any program offered by PKSA Karale.
Student. on behalf
4. CLASSES. Scheduling and content of classes and programs, furnishing of
facilities and provision of instructors to teach and supervase classes and
practice sessions are at the sole and absolute discretion of the PKSA Karate
location and may be changed at any lime by the PKSA Karate location By
signing this Agreement, the Student receives membership at a greatly reduced
price. Student understands and agrees that additional fees such as examination
and/or testing fees may not be included in the price of this Agreemeni. The
PKSA Karate location may rejse the tuition rate of ongoing memberships by
providing advance notice equal to the notice peraod required for cancellation
stated herein.
5. SIGNATORIES. Any person(s) sign;ng this Agreement whether as a Studenl.
co-signer or otherwise shall be jointly. severally and individually liable to PKSA
Karate and Key Web Enterprises DBA PKSA.com for the full contract price as if
such person signed as the Student. All persons signing this agreement assume
responsibilrly for all costs of collection, including but not limited to collection
agency fees, court costs. attorney's fees. and late charges that may be incuned
in the event of a default Any person(s) stgning lhis agreement authorizes the
use of a disclosed e-mail address for billng and marketing purposes
€ncel the Agreement if Student or the PKSA
Karate location moves more than 25 miles from the PKSA Karate location
curent location.
proof of relocation, Student may
and
acknowledges that e-mail text rnay include financial infomation pertaining to
the membership.
6. COMPLIANCE WITH LAWS. This Agreement shall be governed by ihe lavrs
of the State in which the PKSA Karate location is located. All rights and
obligations of the PKSA Karate location and Student uncier this Agre€ment are
subject to all applicable federal. state and local laws and regulations. To the
exteni that the terms and conditions of this Agre€ment conflict with any
applicable statute, rule or requlation in effect at the time of execution of this
Agreement governing transactions of the type contained herein, the ,Agreement
shall be deemed revised to conform with such statutes. rules and regulations.
The PKSA Karate location and Student shall be bound by the modifEd
Agreement and agree that no other modifications shall be enforceable unless in
writing and signed by the parties. This Agreement constitutes the entire
Agreement between the parties and supersedes all prior agreements between
10. CANCELLATION. This Agreement may be cancelled by Student for any
reason vr'ithout penalty or further obligation at any time prior to midnight on the
third business day after you sign this Agreement (the "Right to Caneel"). Notice
of cancellation. in writing. stating that you do not wish to be bound by this
Agreement must be delivered or mailed to PKSA Karate location by certified
mail, retum receipt requested within the time period provided above. All money
paid shall be refunded by the PKSA Karate location within 30 days ot the
exercise of the Right to Cancel except that the PKSA Kerate location may retain
exp€nses actually incuned and the portion of the total price representing the
services used and completed based on an hourly rate of 935lhour. Payments
made at the time of enroliment or execution of this Agreement are nonrefundable after 3 days
The Student understands that after the Right to Cancel expires. exc€pt as
specificaliy provided herein. this Agreement may nol be canceied and all
payments ihrough the end ol the Agreement shall be due and payable as
provided herein, To cancei this Agreement pursuant to any right contained
herein, other than the Right io Cancel set forth above, the student shall submit
to the PKSA Karate location a mmpleted Cancellation Form, which can be
obtained from the PKSA Location. by certified mail retum receipi requested, or
by personal delivery to the address specified in this Agreement for PKSA
Location. Within 30 days of receipt of the Cancellation Form, any money to be
refunded to the Student shall be paid by the PKSA Karate location and any
automatic transfer shall be canceled. lf the Student has executed a credit, lien
or automatic funds transfer Agreement to pay for services, any such Agreemenl
executed by the Student shall be destroyed. Failure to utilize the services or
instruction provided by Business does not constitute or imply notification to or
cancellation of this Agreement. Membership is cancelled when all payments
due within the specilied notificatton penod have been received. lf a. notification
period is not specified, 30 days notice is implied. Student retains membership
rights and privileges until the notic€ period expires.
1'1. DEFAULT. Non-payment of scheduled monthly payments in excess of 60
days shail constitute default under this Agreement. lf thi6 Agreement is in
defauit. the entire amount cwed hereunder shall become immediately due and
payable. litigation may be initiated to collect all amounts due or the account
refened to collection. ln the event of default in payment or breach of lhis
Agreement. PKSA Karate andior PKSA Karate location shall be entitled to
recover their reasonable attomey's fees. court costs. and, if applicable. interest
on any past due amount at the rate ol 1.5o/a p$ month and a collection fee
equal to 20% as a collection fee and not a penalty, to collect any past due
amounts or cure any breach.
12. CONSUMER NOTIFICATION. Key Web Enlerprise. LLC, DBA PKSA.com,
tuitaon on behatf of PKSA
Karate. PKSA.com is a bil,ing company not a collection agency or finance
company. However, PKSA.com may refer an account to collection agency or
attomey for debt collection and/or credit reporting.
is an aulhorized agent to bill and collect Student
PKSA
4090 Johns Creek
PKEALOCATION
ADDRESS &PHOIIE:
Pkwy. 678-835-9588
PLEASE PRINT
BILLING AGREEMENT
GUSTOI'ER BITUHG INFORTIATION
Customer
This agreement and contract for services
(First & Last Nane):
and/or instruction is made between the PKSA
location and Customer/Student. Key Web
Enterprises, LLC, DBA PKSA.com is the
DOB: -
Email Address:
(
Primary Phone:
Billing
Cell Phone:
)
(_J
-
service provider for Customer billing and
servicing of PKSA Karate. PKSA.corn will
-
appear on your bank or credil card statement.
Any account more than 5 days due will be
charged a $10.00 late fee unless otherwise
Address:
U
ls above Customer also a student?
Student 1
stated herein. Any returned ACH payment will
be assessed $25.00. CrediUDebit card
chargeback fee is $35.00. Any unsuccessful
scheduled electronic transaction is subject to a
zip
State:
Crty:
Yes
Druo
$10.00 processing fee. PKSA.com is not
responsible for any bank fees incurred by
Customer. PKSA.com has the sole right to
DOB_-_-_
DOB--
(First & Last
Student 2
(First
modify any payment due date and to resubmit
retumed or declined items (plus applicable
fees) without pnor notice. lf the Billing Method
is modified during the term of this Agreement,
the payment amount may be adjusted
accordingly (if applicable, by PKSA location).
PROGRAfl DESCRflPNOil:
A. O TERil
Number of
Monthly Pymts
Monthly Pymt
Amount
n
(Compl€te only A & A1 or B)
lnitial Pymt
O
$
Total Program
Amount
tnfiat Pymt
Paid
Program
No. Pymts
Remaining
s
lf you wish to cancel this Agreement, you may
Start Date
cancel by delivering or mailing by certified
Program
End Date
the PKSA location. The notice must say you
mail, return receipt requested, written notice to
do not wish to be bound by the Agreement and
lf aub-renewal
41. AUTOTATIE RENEWAL OPTIOI{
CUSTOMER/STUDENT'S
RIGHT TO CANCEL
Day of Month
Du€ Date
Oue Date
b selecGd, upon Program Expiration
Date
AgreerEnt will conlinually renew as set forth below with
the same billing method, frequency and due date- Length of the renetval period b determined by type (Open or
Term). PKSA Karato must receivo written notice not less than 30 da)B prior to Progrem Expiration to tarminate a
scheduled aub-renewal. lf the Agreement rene[s, termination is govemed by the reneyval type.
O Open
Renewal
A Term
Payment
Amount
(Unless otheMise stated, a 30 - day
written cancdlation notice is rcquared.)
Memberships onv)
Ongoing Monthly
Cancollation
Notice (Days) I
lnitial Payment
Paid Date
Day of Month
Due Date
Payment Amount
I
(Unl6s otheMise stated, a 30 - day
First Recuning
Payment Date
written cancdhtim is required.)
List of Additional Charges
BltUt{G HETHOD O
O
Additional
Amount
(Registration, Uniforms, etc.)
nCX Checking
O
CreOiUOeOit
Card O Statement (dirionat$10
paid
monihryfee)
Acd#
O c.oiuotuit
lf the PKSA Karate location goes out ol
business or refuses to give you a refund, there
may be a bond or letter of credit under which
you are entitled to collect. PKSA.com will not
be responsible for any refunds. Enforcement
of applicable consumer statues is by your state
or local Consumer Affairs Office.
I have read and understood this entire
Agreement and I agree to comply with all the
provisions, terms, and conditions set forth on
both sides of this Agreement including but not
limited to paying the Total Program Amount. I
further agree that once signed, this Agreement
is a legally binding and enforceable obligation.
I acknowledge I have received a copy of this
agreement.
PKSA.com
ACH Checking
Bank
Name
Checking
delivered or mailed to the PKSA location at the
addresses set forth herein. lf you cancel, any
price.
(Each reneryal tem is for lhe sme ProgEm Length. To c6ncd, PKSA
must recdve written notice not le63 than 30 days prior to the e)piration
date of alry Renevral Tem. lf renerved, you are responsible bf entire
Reneml Term.)
Days
Print Customer Name
Cau
nccount Number (V|SA, uastercard,'l{
d6;;;;;;t"di
Customer Signature
A late fee
f
of I $------l
(3 digite back of card)
I
will be assessed for any payrnent
L__]d"V"
past due.
Authorized PKSA Karate Representative
tf not specifed a late fee of $l 0 will be due for any pavment 5 davs mst due.
SPEE|AL NSTRUCTIOilS
(or Additional Str.rdents)
12
midnight of the third business day afier you
sign this Agreement. The notice must be
down payment or initial fee may not be
refundable and the PKSA location may be
entitled to a portion of the total Agreement
Reneriral lncrease
-Renemt eymsl
lQz" O$
Payment f---------l
Program
Amount l*
I Length
Cancellation
Notice
B. O OPEil (br ongcrng
No.
must be delivered or mailed before
Date (mnfdd/yy)