Name *
Name
Address *
Address
Phone *
Phone
Gender
Date of Birth *
Date of Birth
Plan A *
Plan A - Annual membership only (mandatory) - $25.00 ANNUAL MEMBERSHIP entitles you access to ALL TEI workshops, and special pricing for all Off Site Events.
Plan B
Plan B - Annual membership PLUS - $20.00/month due month two of contract and every month thereafter MEMBERSHIP entitles you access to ALL TEI Martial Arts, Yoga, Meditation, workshops and special pricing for all Off Site Events. a Gi(Uniform( after 10 classes, and your first month of classes FREE.
Plan C
Plan C - OPTIONAL SAVINGS PLAN - $25/annual membership + 9 months at $20 .00/month = $205.00 due upon signing. This is a $40.00 savings!
Please consider making a tax deductible donation in addition to your membership.
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$
Payment Method *
Please select how you would like to pay
Expiration Date
Expiration Date
The Member hereby understands and authorizes APS to deduct membership dues directly from the following bank or credit card account according to the terms of this agreement.                                                                                                                        The Member authorized APS to electronically deduct payment on or after the due date for each consecutive billing cycle according to the terms of this agreement. Member agrees to have funds available at least 3 days prior to due date and will pay a service fee of $10.00 on any item presented for collection and/or returned for any reason.                                                                                                                                                                                                                                                                                                                                                                                                                              Please Initial below.
Expiration Date
Expiration Date
I understand I am signing an agreement which may be used by a financial institution to process my payments. All payments must be paid in full to the financial institution and may not be suspended for any reason whatsoever and no monies will be refunded. My failure to attend classes does not relieve me of my financial obligation as outlined in my membership agreement and this contract.                                                                                                                                                                                                                                                                                                    
Date
Date
1. Third Eye Insight membership is valid for the person listed on the application, memberships cannot be transferred to another individual.                                                                                                                                                                                               2. Third Eye Insight membership includes participation in all TEI classes for the applicable year membership is paid.              3. Additional rights to membership cancellation, you or your estate may cancel this agreement for the following reasons: if upon doctor's order you cannot physically or medically participate in classes, or if you relocate to a different state.                                                                                                                                                                                                                                                 4. If a member is under the age of 18, the parent or legal guardian signing below agrees to the terms and conditions of the agreement on behalf of said member.                                                                                                                                                          5. As a member I agree to all the rules and regulations which are in place to protect all members from injury. I recognize the risks inherent in sports and activities such as those conducted at Third Eye Insight.                                                                          6. If Third Eye Insight has to enter into litigation over collection procedures of any kind, the member, parent or guardian will be responsible for any legal fees incurred.                                                                                                                                                                                                                                7. The member has been made aware that the practice of martial arts and self-defense involves the risk of injury/ death and agrees to follow the directions of the instructors so as to minimize said risk of injury/ death.                                                             8. Member gives Third Eye Insight permission to use their picture, videos and voice in any way for advertisement purposes herein.                                                                                                                                                                                                                    9. Third Eye Insight has the right to cancel any membership due to improper behavior or lack of moralfortitude.                                                                                                                                                                                                                                                                                   10. The member, or parent or legal guardian of member, freely and voluntarily agrees on behalf of Student and his or her heirs, personal representatives, executors, administrators, agents and assigns, to assume all risks of their decision to participate in this training program and agrees to be responsible for their own welfare. Student accepts any and all risks of delay, unanticipated events, disease or illness, injury, emotional trauma and death associated with their training program at THIRD EYE INSIGHT. Student agrees to hold THIRD EYE INSIGHT, Devin Fernandez, Allie Alberigo, the School, volunteers, employees and other Students harmless and waives any rights for claims for injury, disease, sexual harassment, demands, obligations, action, causes of action, losses or expenses of any nature whatsoever associated with THIRD EYE INSIGHT. Student intends his or her signature below to be a complete and unconditional release of liability to the greatest extent allowed by law and verifies this statement.
Date
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