5146 Old Redwood HWY Santa Rosa CA. 95403 (707) 544-2302
Wings Martial Academy of Fine Arts
Enrollment Date __________________ Start/End Date(s)______________________ Referred by _______________________
Students Name(s ) __________________________DOB_________ Name _______________________________ DOB__________
Students Elementary/Middle School(s) ___________________________________________________________________________
Parent/Legal Guardian Name _________________________________________________________________________________
Billing Address: _________________________________ City: _________________________ State: ______ Zip: _____________
Phone: Res. ________________________ Bus__________________________ Cell ______________________________________
Employer___________________________________________________________________ CDL#: _________________________
Job Title __________________________________________________________________ Date of Birth: ______ / ______ / ______
Spouse/Other Parent ______________________________________________________________________________________
Address: _________________________________ City: _________________________ State: ______ Zip: _______
Phone: Res. ________________________ Bus__________________________ Cell ______________________________________
Employer____________________________________ Job Title ______________________________________________________
Please Note : To reserve your place in our PRE-PAID program Payment is due on Thursday prior to the week attending or if paying monthly by the 25 th of the prior month. With a credit card on file on file and authorization guaranteeing weekly/monthly payment you will have grace period outlined in our admission rules and agreement and avoid Late Fees.. In the event of nonpayment by due date, I authorize my credit/debit card to be for the amount due plus any applicable late fees and/or outstanding balances.
Initial _____ Type of card ______________ Card Number_______________________________ Expiration ________ Security _____
Refer to Wings MAP Program Description and Admission Agreement for the policy descriptions & thoroughly read PRIOR to enrolling your student and signing this agreement.
1. Add late Fee of $35.00
per week for Payments made after the 5 th of the month. Tuition
’ s not paid by the 10 th of the month result
In discontinued service .
2. Returned Check fee
–
Refer to Program Description and Admission Agreement.
3. No Refunds-Refer to Program Description and Admission Agreement.
4. STATE DAY CARE EXEMPTION:
I UNDERSTAND THAT Wings MAP (AFTER SCHOOL MARTIAL & ARTS PROGRAM), IS A MARTIAL ARTS SCHOOL AND NOT A DAYCARE IN
AS SUCH, THEIR STOCK-IN-TRADE IS NOT SUPERVISION AND CARE. THE INTENT OF WINGS MAP IS TO TEACH MARTIAL ARTS PHYSICAL
AND PHILISOPHICAL CHARACTER BUILDING SKILLS. I UNDERSTAND THAT WINGS MAP IS A MARTIAL ARTS SCHOOL AND IS A DROP-IN
FACILITY IN AS SUCH; MY CHILD(REN) IS /ARE FREE TO COME AND GO. ADDITIONALLY, IF MY CHILD(REN) STAY
’
S AT THE WINGS MAP
FACILITY IT IS BECAUSE OF MY DIRECTION AND NOT WINGS MAP.
Initial______________
5. WAIVER AND RELEASE:
Buyer and Student(s) agree that Students engaging in physical exercise, the use of equipment, and the use of Wings MAP and/or Fitness Fanatics training and instruction facility, which can be dangerous to the Student(s)and could cause injury to the Student(s) is voluntarily participating in these activities and the Buyer and Student(s) assume all risks of injury to
Student. Buyer and Student hereby waive and release any claim or right to sue Wings MAP and/or Fitness Fanatics employees and agents for injury to student(s). Buyer and/or student have carefully read this waiver and release and fully understand it is a release of all liabilities and damages to Wings MAP and/or Fitness Fanatics because of any injury that may occur. Wings MAP and/or Fitness Fanatics will make no evaluation or recommendation whether Student(s) or guests physically fit of any exercise activities. It is always advisable to consult your physician before undertaking a physical exercise program, particularly martial arts activities.
Initial______________
Rev 4
Wings Martial Academy of Fine Arts Enrollment Contract Form C Confidential
07/26/2012

I, the undersigned, do hereby agree to abide by the rules, which may be explained verbally or in writing at Wings MAP &
Fitness Fanatics training halls.
In consideration of my membership and/or participation in any activities held by or on behalf of Wings After School Martial &
Arts Program and Fitness Fanatics, I, for myself and my successors, heirs, and assigns, do hereby release and discharge The
WTSDA, Sophia D. Miridakis, Jim Debaca, and/or her/their agents from any and all claims, demands, and causes of action of any nature which I or my heirs and assignments ever may have against them for, on account of, or by reason or arising in connection with any Martial Arts instruction, participation, or any other activity held by or on behalf of Wings MAP and
Fitness Fanatics and hereby waive any claims, demands and causes of action. I further agree that I will not hold my children ’ s
Public School District, and its agents, servants and employees from any and all claims, demands and causes of action of any nature which I or my successors, heirs and assignments may have against them, harmless for any injury to me or accident which may occur in the course of my instruction or my presence at any Wings After school Martial & Arts Programs and
Fitness Fanatics Training hall. I further more agree to binding arbitration should a disagreement arise and to pay all court costs incurred by a legal dispute wherein I am the plaintiff.
Initial_____________
6.
Loss/
Damage/Theft of Student’s Property
Wings MAP does not assume any responsibility for the loss, damage or theft of any property belonging to the Student, and the
Student agrees that the school and its personnel are not responsible for or liable for any such property even if its loss, damage, or
theft occurs on or about the school ’ s facility.
Initial______________
7. Movies ___/ YES I will allow my child to watch “ PG ” rated kids movies with Wings MAP. ___/ NO Please find another activity for my child(ren) to do while the other students watch
“
PG
”
rates films.
8. Modeling Release ___/ YES I hereby give permission to Wings MAP to use my Child’s name and/or photographic likeness in all forms and media for advertising, trade, and any other lawful purposes. . ___/ NO Please refrain from using my child as a model.
1 . Program: Pre-paid Contract. Save 10% Two Installments Save 5% Month to month Weekly Balanced payment Plan
(month to month authorizations may be revoked with 30 days written notice) (Balanced payment plan includes full day camps)
Days Attending: M T W TH F
2. Monthly Fee: 1 st Student_________ 2 nd Student________
4. 1 st Contract installment: ___/___/___
5. 2 nd Contract Installment ___/___/___
Contract = Prepay for full academic year with one payment and save 10%, or Prepay in two installments and save 5% (non-refundable)
(Contract runs one academic season from signature date unless otherwise specified. Balance plan includes Day Camps)
Subsidized Program ___/ YES I will be participating in a subsidized Program (name)________________________
Wings MAP accepts payments from groups under programs such as 4 C ’ s, Sonoma Works, PACAPP, and CPS. These programs have limited guidelines for expenses they cover. Parents and Guardians participating in such programs agree to pay all charges and Family Fees above the limits of these programs as well as extra charges for Martial arts gear, field trips, testing fees etc.
Initial_____________
(refer to) Wings After School Martial Arts Program Description & Admission Agreement
My child/ren will be attending Wings MAP in 2012/2013, and I have read and understand the admission agreement and am able to comply with the rules and guidelines within. I understand that program rules and guidelines are subject to change without notice and it is my responsibility to be aware of the changes as they are posted.
I understand Wings MAP will not provide services to my family unless all paper work is completed and returned.
Name/s of the child/ren:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Name of person legally responsible for the child/ren, adhering to Contract, Admission Agreement, and the Account:
Please Print Name:_____________________________________________________________________________
Rev 4
Wings Martial Academy of Fine Arts Enrollment Contract Form C Confidential
07/26/2012

Signature: _________________________________________________________Date: ______________________
Rev 4
Wings Martial Academy of Fine Arts Enrollment Contract Form C Confidential
07/26/2012