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Six Month Commitment Form

By signing this document, you are agreeing to pay monthly membership dues in the amount indicated by the selected option below. These dues may be paid in person by debit, credit, or cash, or online via Paypal. If the membership fees are not paid by the due date each month, the monthly membership amount will be automatically charged to the debit or credit card you have provided on this form. By providing your payment information on this form, you are giving 10th Planet Jiu Jitsu Grants Pass permission to collect outstanding payments by using the payment method below. No charges will be made to your card if you pay your membership fee on or by the due date.

The below signed also understands that access to 10th Planet Jiu Jitsu Grants Pass's classes and facilities will only be available to members who are current on their payments. 

This agreement is for a 6 month term that begins on the date this form is signed. By signing below, you understand that you are being given a discounted monthly rate that is only available with a 6 month commitment. The fee for canceling this contract before the end of the 6 month term is equal to one month's membership dues. Early termination of your membership requires a 30 day notice given to 10th Planet Jiu Jitsu Grants Pass.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Membership Options
Please Choose A Membership Option*
$100
$120
$140
$150
$160
$250
Card On File

Name On Card

Card Numbers

Expiration Date

CVV Code
Address

Street Address *

City *

State *

Zip *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
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.


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