Click here if you are an existing student who is updating or renewing a plan.

Capoeira Brasil Los Angeles Student Registration Form

Section 1 - Student Info
Name *
Name
Main Phone *
Main Phone
Secondary Phone
Secondary Phone
Date of Birth *
Date of Birth
Emergency Contact *
Emergency Contact
Emergency Contact Phone *
Emergency Contact Phone
Student Type *
Section 2 - Parent Info (Skip if student is an adult or if info is already entered as emergency contact)
Parent/Guardian 1
Parent/Guardian 1
Parent/Guardian 1 Phone
Parent/Guardian 1 Phone
Parent/Guardian 2
Parent/Guardian 2
Parent/Guardian 2 Phone
Parent/Guardian 2 Phone
Section 3 - Membership Agreement
Membership Type *
Are you making a payment today? *
Start Date
Start Date
Terms of Membership - Annual:
The term of the agreement will be for one year. Payment for the class fees for each month will be deducted from the account on this Agreement on the same day each month. If the student must take a leave of absence from training at Capoeira Brasil, this agreement may be suspended. The number of months the student‘s account is on hold will be added on to the term of the student’s year contract. This agreement may be terminated if the student is relocating to a residence further than a 40 mile radius from the Capoeira Brasil Academy located at 5557.W Washington Blvd., Los Angeles, CA 90016. Written proof of change of address is required to terminate this agreement for reason of relocating to a new residence. This agreement may be terminated for reason of physical injury, which prevents a student from participating in the normal activities of class, the recovery time for which a doctor estimates at longer than three (3) months. To terminate for such an injury, the student must provide written notification from a medical doctor indicating that the student is unable to participate in normal class activities for reason of physical injury. This agreement may be terminated at any time by paying a cancellation fee of $200.00. For students permitted to take only a limited number of classes per month, classes missed by the student during one month or week may be added on to the number of classes permitted in the following month or week. For students paying for unlimited classes per month uninterrupted for the entire year, a bonus month will be added to the end of their one-year contract.
Terms of Membership - Month to Month:
The term of the agreement will be for one month. Payment for the class fees for each month will be deducted from the account on this Agreement on the same day each month. While the student may cancel monthly membership at any time, there is no refund or pro-rate for unused portions under any circumstances (including relocation, injury, leave of absence, etc.)
Terms of Membership - Class Card
Class cards valid for exactly three months from the date of purchase.
*
Section 4 - Payment Info
Cardholder's Name
Cardholder's Name
MM/YYYY