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Payment Agreement For Parent's of Kid's Class Participants

The below form is an agreement to have automatic payments charged to the card provided by the parent or guardian of the child participant. 10th Planet Jiu Jitsu Grants Pass does not require contracts to be signed for the kid's class, however a valid debit or credit card is required to be on file.

In order to keep your membership active, payments not received by the due date each month will be automatically charged to the card put on file below. If you wish to cancel your membership, you may do so at any time by contacting 10th Planet Jiu Jitsu Grants Pass and requesting the cancelation.

Cancelation requests made after a payment has already been processed will not be eligible for a refund. 

I Agree

First Parent/Guardian of Participant Name

First Name*

Last Name*

Phone*
First Parent/Guardian of Participant Date of Birth*
I certify that I am 18 years of age or older
First Parent/Guardian of Participant Auto Pay Agreement
Payment Options *
I agree to have my card charged automatically on my payment due date each month.
I do not want my card charged automatically, I will pay in person on my due date or by the next class following my due date.
If you choose to make manual payments instead of being charged automatically, payment must be received by your due date or by the next class following your due date if your due date does not fall on a day that there is class. If payment is not received on time, and you have not contacted 10th Planet Jiu Jitsu Grants Pass to make other arrangements or cancel your membership, your card will automatically be charged to keep your membership active. Do you agree to have your card charged in the event that your payment becomes past due and you have not canceled your membership? *
I agree

DAY OF THE MONTH PAYMENT IS DUE *

Name On Card *

Card Numbers *

Expiration Date *

CVV Code *

Billing Address *

City *

State *

Zip *

TODAY'S DATE *
First Parent/Guardian of Participant Signature*
Second Parent/Guardian of Participant Name

First Name*

Last Name*
Second Parent/Guardian of Participant Date of Birth*
Second Parent/Guardian of Participant Auto Pay Agreement
Payment Options *
I agree to have my card charged automatically on my payment due date each month.
I do not want my card charged automatically, I will pay in person on my due date or by the next class following my due date.
If you choose to make manual payments instead of being charged automatically, payment must be received by your due date or by the next class following your due date if your due date does not fall on a day that there is class. If payment is not received on time, and you have not contacted 10th Planet Jiu Jitsu Grants Pass to make other arrangements or cancel your membership, your card will automatically be charged to keep your membership active. Do you agree to have your card charged in the event that your payment becomes past due and you have not canceled your membership? *
I agree

DAY OF THE MONTH PAYMENT IS DUE *

Name On Card *

Card Numbers *

Expiration Date *

CVV Code *

Billing Address *

City *

State *

Zip *

TODAY'S DATE *
Third Parent/Guardian of Participant Name

First Name*

Last Name*
Third Parent/Guardian of Participant Date of Birth*
Third Parent/Guardian of Participant Auto Pay Agreement
Payment Options *
I agree to have my card charged automatically on my payment due date each month.
I do not want my card charged automatically, I will pay in person on my due date or by the next class following my due date.
If you choose to make manual payments instead of being charged automatically, payment must be received by your due date or by the next class following your due date if your due date does not fall on a day that there is class. If payment is not received on time, and you have not contacted 10th Planet Jiu Jitsu Grants Pass to make other arrangements or cancel your membership, your card will automatically be charged to keep your membership active. Do you agree to have your card charged in the event that your payment becomes past due and you have not canceled your membership? *
I agree

DAY OF THE MONTH PAYMENT IS DUE *

Name On Card *

Card Numbers *

Expiration Date *

CVV Code *

Billing Address *

City *

State *

Zip *

TODAY'S DATE *
Fourth Parent/Guardian of Participant Name

First Name*

Last Name*
Fourth Parent/Guardian of Participant Date of Birth*
Fourth Parent/Guardian of Participant Auto Pay Agreement
Payment Options *
I agree to have my card charged automatically on my payment due date each month.
I do not want my card charged automatically, I will pay in person on my due date or by the next class following my due date.
If you choose to make manual payments instead of being charged automatically, payment must be received by your due date or by the next class following your due date if your due date does not fall on a day that there is class. If payment is not received on time, and you have not contacted 10th Planet Jiu Jitsu Grants Pass to make other arrangements or cancel your membership, your card will automatically be charged to keep your membership active. Do you agree to have your card charged in the event that your payment becomes past due and you have not canceled your membership? *
I agree

DAY OF THE MONTH PAYMENT IS DUE *

Name On Card *

Card Numbers *

Expiration Date *

CVV Code *

Billing Address *

City *

State *

Zip *

TODAY'S DATE *
Fifth Parent/Guardian of Participant Name

First Name*

Last Name*
Fifth Parent/Guardian of Participant Date of Birth*
Fifth Parent/Guardian of Participant Auto Pay Agreement
Payment Options *
I agree to have my card charged automatically on my payment due date each month.
I do not want my card charged automatically, I will pay in person on my due date or by the next class following my due date.
If you choose to make manual payments instead of being charged automatically, payment must be received by your due date or by the next class following your due date if your due date does not fall on a day that there is class. If payment is not received on time, and you have not contacted 10th Planet Jiu Jitsu Grants Pass to make other arrangements or cancel your membership, your card will automatically be charged to keep your membership active. Do you agree to have your card charged in the event that your payment becomes past due and you have not canceled your membership? *
I agree

DAY OF THE MONTH PAYMENT IS DUE *

Name On Card *

Card Numbers *

Expiration Date *

CVV Code *

Billing Address *

City *

State *

Zip *

TODAY'S DATE *
Sixth Parent/Guardian of Participant Name

First Name*

Last Name*
Sixth Parent/Guardian of Participant Date of Birth*
Sixth Parent/Guardian of Participant Auto Pay Agreement
Payment Options *
I agree to have my card charged automatically on my payment due date each month.
I do not want my card charged automatically, I will pay in person on my due date or by the next class following my due date.
If you choose to make manual payments instead of being charged automatically, payment must be received by your due date or by the next class following your due date if your due date does not fall on a day that there is class. If payment is not received on time, and you have not contacted 10th Planet Jiu Jitsu Grants Pass to make other arrangements or cancel your membership, your card will automatically be charged to keep your membership active. Do you agree to have your card charged in the event that your payment becomes past due and you have not canceled your membership? *
I agree

DAY OF THE MONTH PAYMENT IS DUE *

Name On Card *

Card Numbers *

Expiration Date *

CVV Code *

Billing Address *

City *

State *

Zip *

TODAY'S DATE *
Seventh Parent/Guardian of Participant Name

First Name*

Last Name*
Seventh Parent/Guardian of Participant Date of Birth*
Seventh Parent/Guardian of Participant Auto Pay Agreement
Payment Options *
I agree to have my card charged automatically on my payment due date each month.
I do not want my card charged automatically, I will pay in person on my due date or by the next class following my due date.
If you choose to make manual payments instead of being charged automatically, payment must be received by your due date or by the next class following your due date if your due date does not fall on a day that there is class. If payment is not received on time, and you have not contacted 10th Planet Jiu Jitsu Grants Pass to make other arrangements or cancel your membership, your card will automatically be charged to keep your membership active. Do you agree to have your card charged in the event that your payment becomes past due and you have not canceled your membership? *
I agree

DAY OF THE MONTH PAYMENT IS DUE *

Name On Card *

Card Numbers *

Expiration Date *

CVV Code *

Billing Address *

City *

State *

Zip *

TODAY'S DATE *
Eighth Parent/Guardian of Participant Name

First Name*

Last Name*
Eighth Parent/Guardian of Participant Date of Birth*
Eighth Parent/Guardian of Participant Auto Pay Agreement
Payment Options *
I agree to have my card charged automatically on my payment due date each month.
I do not want my card charged automatically, I will pay in person on my due date or by the next class following my due date.
If you choose to make manual payments instead of being charged automatically, payment must be received by your due date or by the next class following your due date if your due date does not fall on a day that there is class. If payment is not received on time, and you have not contacted 10th Planet Jiu Jitsu Grants Pass to make other arrangements or cancel your membership, your card will automatically be charged to keep your membership active. Do you agree to have your card charged in the event that your payment becomes past due and you have not canceled your membership? *
I agree

DAY OF THE MONTH PAYMENT IS DUE *

Name On Card *

Card Numbers *

Expiration Date *

CVV Code *

Billing Address *

City *

State *

Zip *

TODAY'S DATE *
Ninth Parent/Guardian of Participant Name

First Name*

Last Name*
Ninth Parent/Guardian of Participant Date of Birth*
Ninth Parent/Guardian of Participant Auto Pay Agreement
Payment Options *
I agree to have my card charged automatically on my payment due date each month.
I do not want my card charged automatically, I will pay in person on my due date or by the next class following my due date.
If you choose to make manual payments instead of being charged automatically, payment must be received by your due date or by the next class following your due date if your due date does not fall on a day that there is class. If payment is not received on time, and you have not contacted 10th Planet Jiu Jitsu Grants Pass to make other arrangements or cancel your membership, your card will automatically be charged to keep your membership active. Do you agree to have your card charged in the event that your payment becomes past due and you have not canceled your membership? *
I agree

DAY OF THE MONTH PAYMENT IS DUE *

Name On Card *

Card Numbers *

Expiration Date *

CVV Code *

Billing Address *

City *

State *

Zip *

TODAY'S DATE *
Tenth Parent/Guardian of Participant Name

First Name*

Last Name*
Tenth Parent/Guardian of Participant Date of Birth*
Tenth Parent/Guardian of Participant Auto Pay Agreement
Payment Options *
I agree to have my card charged automatically on my payment due date each month.
I do not want my card charged automatically, I will pay in person on my due date or by the next class following my due date.
If you choose to make manual payments instead of being charged automatically, payment must be received by your due date or by the next class following your due date if your due date does not fall on a day that there is class. If payment is not received on time, and you have not contacted 10th Planet Jiu Jitsu Grants Pass to make other arrangements or cancel your membership, your card will automatically be charged to keep your membership active. Do you agree to have your card charged in the event that your payment becomes past due and you have not canceled your membership? *
I agree

DAY OF THE MONTH PAYMENT IS DUE *

Name On Card *

Card Numbers *

Expiration Date *

CVV Code *

Billing Address *

City *

State *

Zip *

TODAY'S DATE *
Parent or Guardian's Email Address

Email*
A signed copy of this waiver will be sent to the email address you provide.
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*
I certify that I am 18 years of age or older
Parent or Guardian's Auto Pay Agreement
Payment Options *
I agree to have my card charged automatically on my payment due date each month.
I do not want my card charged automatically, I will pay in person on my due date or by the next class following my due date.
If you choose to make manual payments instead of being charged automatically, payment must be received by your due date or by the next class following your due date if your due date does not fall on a day that there is class. If payment is not received on time, and you have not contacted 10th Planet Jiu Jitsu Grants Pass to make other arrangements or cancel your membership, your card will automatically be charged to keep your membership active. Do you agree to have your card charged in the event that your payment becomes past due and you have not canceled your membership? *
I agree

DAY OF THE MONTH PAYMENT IS DUE *

Name On Card *

Card Numbers *

Expiration Date *

CVV Code *

Billing Address *

City *

State *

Zip *

TODAY'S DATE *
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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