Membership Suspension Request - Rocky Silva's American Karate

I'm submitting this request on behalf of: *

My student
Myself (I am a student 18 years or older)

Student's Full Name *

Guardian's Full Name *

Student's Full Name *

Student's Current Belt *

Student's Current Class *

Email *

Phone *

The following form serves as a request to pause or cancel a student’s membership for a set number of months. Only full calendar months may be canceled or suspended. Any month that is partially attended will be charged the full monthly tuition. Below is the pertinent information regarding this process.

There are 2 options for students when making changes to their membership: *

Option 1 – Membership Pause & Automatic Restart
Option 2 – Cancellation of membership with NO specific return date

Option 1

To hold your students’ spot in their current class, RSAK requires your return month’s tuition to be paid now, in advance, as a deposit. Upon receipt of this form, RSAK will charge the account on file the normal tuition rate for your student for the 1 month they plan to return. Upon return, this payment will already be noted on their account and no additional payment will be required as it is paid in advance to reserve their spot in the program. This is the only option to 100% guarantee a spot in your student’s class upon return. This amount is non-refundable. Any months you have checked as pausing will not incur a charge of any kind.

Option 2

This option allows families to assess when their best return date would be; however, it does not guarantee that there will be an available spot in the student’s class upon your return. RSAK reserves the right to limit class size and utilize waiting lists to best allow new students and current students the opportunity to grow in the best environment possible. No future payments will be charged beginning with the month you have selected above.

What month will you be ending your membership? *

Either for myself, as a student age 18+, or on behalf of the student under age 18, I hereby acknowledge that I have carefully read and understand all the above options for editing a student’s membership and assume all responsibility, both financial and scheduling wise, based on the above information I have provided. I give RSAK permission to edit my student’s membership and apply any tuition payments or fees that may be applicable. I acknowledge that by not filling this form out in any way automatically selects OPTION 2 stated above by default. *

I acknowledge the above statement

Signature (type out your full name) *

By typing out my name in place of a signature, today's date, and submitting this form, I am providing my acknowledgement and consent to the above selected option.

Today's Date *

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