2024/2025 DYMA AFTER SCHOOL REGISTRATION

PARENT/LEGAL GUARDIAN'S INFORMATION

Parent 1 Full Name *

Phone Number *

Email Address *

Parent 2 Full Name

Phone Number

Email Address

Emergency Contact Name *

Relationship *

Secondary Phone *

Primary Phone *

STUDENT INFORMATION

First Member's Full Name *

Grade / Date of birthday(MM/DD/YR) *

ELEMENTARY SCHOOL NAME *

Second Member's Full Name

Grade / Date of birthday(MM/DD/YR)

ELEMENTARY SCHOOL NAME

Third Member's Full Name

Grade / Date of birthday(MM/DD/YR)

ELEMENTARY SCHOOL NAME

What Location Are You From? *

Which DYMA Location Will You Attend? *

Purcellville

Brambleton

Is there anything we should know about your child? (allergies, medication, etc.)

DETAILS

2024-2025 PRICING (Prices may be changed!)

*NEW MEMBERS: Check "Registration and Uniform - New DYMA Member" *

2 Days per Week ($120) - Current DYMA Member

3 Days per Week ($150) - Current DYMA Member

5 Days per Week ($170) - Current DYMA Member

Registration Fee ($100) and Uniform ($60) - New DYMA Member

NEW MEMBERS: CHOOSE DAYS

5 days $170

3 days $150

2 days $120

Three or Two Day Options: CHOOSE DAYS

BREAKDOWN FOR NEW MEMBERS:

- Registration Fee is $100

- Uniform Fee is $60

- Weekly After School fee is determined by # of days (2, 3, or 5 days a week)

First week deposit is required and there are no refunds.

Card Type *

Card Number *

Exp. Date *

V-Code

Comments

Authorization *

I authorize Dragon DYMA Martial Arts to charge my credit card and I understand that there are no refunds regardless of attendance.

This Program Includes:

- Homework Assistance

- Taekwondo Classes

- Physical Exercise Class

- Arts, Crafts, STEM, and Fun Games

- K to Middle School

- Follow all State Regulation Guidelines

- Safe & Clean Environment

- Class size is limited

Terms and Waiver:
I agree to waive any and all claims against Dragon DYMA Martial Arts and all people connected with it. This contract serves as permission to have my child(ren) transported to any health care facility and for him/her to receive any and all emergency health care should the situation arise.

As we are all aware, children are prone to mishaps. Although Dragon DYMA Martial Arts makes every effort to have adequate supervision, occasionally accidents can happen. In the instance that an emergency arises, we would need your specific permission to transport and have your child treated by a professional care giver/physician, etc. DYMA will not be responsible for any liabilities issues occurred.

For the safety and well being of our students and staff, Dragon DYMA Martial Arts reserves the right to remove any child from our program.

By signing below, I verify that all the above information is correct and that I agree to the terms stated above.

Signature of Applicant/Parent/Guardian *

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Click the Submit Button at the bottom to complete your application!

ONCE WE HAVE SUCCESSFULLY RECEIVED YOUR APPLICATION, WE WILL CONTACT YOU TO DISCUSS PAYMENTS & OTHER DETAILS.

PURCELLVILLE

310 N 21st St, Purcellville, VA 20132

571-271-8039 /540- 338- 6660

BRAMBLETON/DULLES/MOOREFIELD

22895 Brambleton Plaza #110, Brambleton, VA 20148

571-271-8039 / 703 - 542 - 7326