Fill - Free fillable Program Enrollment Form PDF form

CREATED 12/01/19 REV 07/07/20

Program Enrollment Form

THE SALVATION ARMY RAY AND JOAN KROC CORPS COMMUNITY CENTER

Questions? Email info@KrocCenterHawaii.org • 91-3257 Kualakai Parkway • Ewa Beach, HI 96706 • 808.682.5505 • Fax: 808.682.5501 • KrocCenterHawaii.org

MEMBERSHIP INFO

IF PARTICIPANT IS CURRENTLY A KROC MEMBER:

 MEMBERSHIP #

SECONDARY EMERGENCY

CONTACT

FIRST NAME

LAST NAME

RELATIONSHIP

PHONE

PARTICIPANT INFORMATION

CLASS INFORMATION

PARTICIPANT NAME FIRST, MIDDLE, LAST

HOME ADDRESS

CITY STATE ZIP

PARTICIPANT DATE OF BIRTH  MALE  FEMALE

PARENT/GUARDIAN NAME

CELL HOME PHONE

LIABILITY WAIVER

Please read this Waiver carefully as it aects your legal rights in the event of an injury, contraction of a

communicable disease, infection and/or damage to property. By signing this document you are representing that

you have read, understood and agree to be bound by the Terms of this Waiver. I understand that entry into and use

of the facilities and equipment at The Salvation Army Kroc Center may involve risk of bodily injury, property damage,

contraction of a communicable disease and/or contraction of a viral or bacterial infection and I agree to assume any

such risks. I understand that it is up to me to consult physicians and other professionals to make sure that I (or the minor

for whom I sign) can safely participate in activities and events at The Salvation Army Kroc Center. I also understand

and agree that by signing this Agreement, I am giving up my (or the minor for whom I sign is giving up) rights to make

any claim or ﬁle a lawsuit and/or action against The Salvation Army, its agents, employees and volunteers, including,

but not limited to, the right to bring a claim against or sue them, for bodily injury, property damage, contraction of a

communicable disease and/or contraction of a viral or bacterial infection of any type and/or any other loss that I might

suer while using The Salvation Army Kroc Center facilities and services, except as limited by law.

NOTICE - In order to promote a safe and secure environment, Kroc Center Hawaii has placed video cameras

in various locations. As part of our commitment to the safety of children and vulnerable persons, Kroc Center

Hawaii reserves the right to consult public sources to determine whether any member or guest of any member

poses an unreasonable risk of harm to its patrons, sta, or visitors. Kroc Center Hawaii may use the above listed

participant’s photo for promotional purposes. For information regarding Kroc Center Hawaii’s cancellation policy,

please see the Program Guide.

PARTICIPANT NAME PLEASE PRINT

DATE

PARTICIPANT SIGNATURE AGE 18+

PARENT/GUARDIAN SIGNATURE

IF PARTICIPANT IS UNDER AGE 18

REG # CLASS CLASS

DATE

CLASS

TIME

CLASS

FEE $

SUBTOTAL $

LESS MEMBER 10% DISCOUNT -

GRAND TOTAL $

• JUDO CLUB (BEGINNER & ADVANCED)

• KROC DANCE ACADEMY (ALL)

IF ENROLLING IN THE FOLLOWING CLASSES,

*AUTOMATIC MONTHLY PAYMENTS ARE MANDATORY.

PLEASE COMPLETE PAGE 2.

IMPORTANT

• PRIVATE MUSIC (ALL)

• SWIM TEAM (GUPPIES, RIPTIDES, RAPIDS)

*Exception for Scholarship recipients.

CREATED 12/01/19 REV 07/07/20

Monthly Automatic Payment

Authorization Form

FOR PROGRAMS: JUDO CLUB  KROC DANCE ACADEMY  PRIVATE MUSIC  SWIM TEAM

Questions? Email info@KrocCenterHawaii.org • 91-3257 Kualakai Parkway • Ewa Beach, HI 96706 • 808.682.5505 • Fax: 808.682.5501 • KrocCenterHawaii.org

GENERAL POLICIES FOR PROGRAMS

• Auto pay will be charged to the same card used to pay for monthly membership.

• Auto pay forms must be received by the 10th of the month in order for auto bill to take place on the 20th for services in the next month.

• Program service fees are not transferable between members.

• Renewal of monthly services will occur automatically on or around the 20th of each month for the next month’s services.

• REFUNDS: no refunds will be issued for any reason including, but not limited to illness. For members that are unable to continue due to medical reasons, refunds will

be considered on a case-by-case basis.

• All automatic payments will be processed in one (1) transaction. Your bank/credit card statement will reﬂect a charge by “The Salvation Army.”

MEMBER INITIALS: ________

CHANGE, CANCELLATION, OR SUSPENSION OF PROGRAM SERVICES

Just as members can suspend their membership, program participants may also suspend their monthly program dues.

1. Suspension or cancellation forms must be submitted to the Program Manager before the 10th of the month in order to cancel or suspend monthly lessons beginning the next

month. For instance, if a student wants to stop lessons on December 1, we need to receive their suspension/cancellation form before November 10th.

MEMBER INITIALS:

________

2. Suspensions due to travel, medical emergency or military orders may be granted for up to one-month at a time. Members may suspend their program auto pay for up to 3

months in a year with documentation. We cannot guarantee the same schedule once the suspension period is over. MEMBER INITIALS:

________

Sign and complete this section to authorize The Salvation Army Ray & Joan Kroc Corps Community Center (“Kroc Center Hawaii”) to make a debit to your credit card listed below.

By signing this form you give us permission to debit your account monthly for the amount indicated on or after the indicated date.

I ____________________________________________________ authorize The Salvation Army Kroc Center Hawaii to automatically charge my credit card account on ﬁle

indicated below monthly for $_________________ starting on or after the 20th of ______________________. This payment is for ___________________________________.

BILLING ADDRESS CITY, STATE, ZIP

PHONE NUMBER EMAIL

SIGNATURE DATE

I authorize the above named business to charge the credit card indicated in this

authorization form according to the terms outlined above. This payment authorization

is for the goods/services described above, for the amount indicated above only, and to

be charged monthly during the duration that the participant is enrolled in the described

program. I certify that I am an authorized user of this credit card and that I will not dispute

the payment with my credit card company; so long as the transaction corresponds to the

terms indicated in this form.

CARDHOLDER NAME (AS IT APPEARS ON THE CARD)

AMOUNT MONTH DESCRIPTION OF GOODS / SERVICES

ACCOUNT TYPE  VISA  MASTERCARD  AMEX  DISCOVER EXPIRATION DATE

CARDHOLDER NAME

ACCOUNT NUMBER CVV2 3DIGIT OR 4DIGIT #

FOR NONMEMBERS & ANNUAL MEMBERSHIP HOLDERS:

SECTION BELOW THIS LINE WILL BE SHREDDED

OFFICE USE ONLY  RECEIVED BY

DATE

CC VERIFICATION CC MATCHES CARD ON FILE

Please charge my card on ﬁle.

MEMBER INITIALS LAST 4 DIGITS OF CC  MASTERCARD  DISCOVER

CARDHOLDER SIGNATURE

FOR MEMBERS

 VISA  AMEX  EFT  ACCOUNT NUMBER:

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