Ultimate Martial Arts & Fitness Inc Waiver

Waiver For? MySelf My Child/Dependent

How did you Hear About Us?
Do you have any Medical Concerns?

No/Yes(Please List) Yes No

(if yes, you must submit a doctor's note specifically stating you are fit to participate in a high intensity fitness workout)
Please list your medical concerns

I confirm that I am the legal guardian and authorize him/her to join Ultimate Martial Arts & Fitness Inc.


  • I (we) (the releaser, which term includes my heirs, executors, administrators, and assigns), in consideration of my acceptance as member of UKB Women (Ultimate Martial Arts & Fitness Inc.) (the releases, which term includes the heirs, executors, administrators and assigns of the releases), from all manner of actions, causes of action, claims or demands which I, the releaser, now have or may hereafter have against the releases, in any way arising out of an accident occurring on or about the premises of UKB Women (Ultimate Martial Arts & Fitness Inc.) whether or not occasioned by the negligence of the releases. I (We) acknowledge that any prior medical history, or condition that arises after signing this release form, that may affect my health or physical well – being, or the health or physical well being of another party (including pregnancy) while participating in the programs at UKB Women (Ultimate Martial Arts & Fitness Inc.) must be disclosed in writing and signed by the club Owner before attending classes. The club Owner reserves the right to freeze, or terminate the parties membership based on this information.

Pre-Authorized Debit (PAD)

  • I (we) authorize UKB Women (ULTIMATE MARTIAL ARTS & FITNESS INC.), to process a debit, in paper, electronic or other form in the amount specified as per membership type; on going bi-weekly and/or a one time payment as per prepaid memberships.
  • I (we) have read and understood all the provisions contained in the terms and conditions of the pre-authorized payment authorization and that I (we) have received a copy. Payment will continue to be debited until payer Cancels or Freezes (a maximum of 3 months) on an UKB Amendment form in person, (email and phone calls are not accepted) provided there are no outstanding payments.

Interruption of service, and Cancellation or Hold of Account(s)

  • A. Membership can be frozen for a Maximum of 3 months. Holds or Cancellations of services requires 30 day notice in person on a Membership Amendment Form. Payer can not cancel or freeze membership with any outstanding payments.  Use of the service is at the discretion of the member. Unused services do not constitute grounds for credits or refunds.
  • B. Prepaid memberships cannot be refunded. Any holds do not affect payment schedule and will extend term for the same duration.
  • C. In the event of pregnancy, memberships must be frozen for safety reasons. Appropriate arrangements will be made by Ultimate Kickboxing for Women.
  • D. All students under the age of 18 must be accompanied by an adult to all classes and have a Youth Membership Agreement completed by a legal guardian or parent. 
  • E. If by any reason of death or permanent disability, the participant is unable to complete the program, he/she shall be relieved of the obligation of making payment other than for services performed prior to death or onset of disability.

Delinquent Payments

  • Late payments will be subjected to a $25 (+ any applicable tax) service charge.
  • In the event of a delinquent payment, the payer agrees to either: pay the balance (bi-weekly tuition and service charge) in full in person, or be billed for the owing bi-weekly tuition and the service charge during the next payment.

Signature Here Please

Electronic Signature Consent *

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.