DYMA In-Person Class Application

After submitting the application, we will contact you to confirm class start date and answer any questions you may have prior to the start of class. Please contact Director Jin with any questions 540-338-6660.

Sponsor/Guardian First Name *

Sponsor/Guardian Last Name *

Email Address *

Phone Number *

Home Address: *

City *

State *

Zip Code *

Best contact number:

Member Name: 1 *

Member 1 DOB (MM/DD/YY) *

Member Name 2

Member 2 DOB (MM/DD/YY)

Member Name: 3

Member 3 DOB (MM/DD/YY)

Is either parent Loudoun County Public Schools Staff? *

Where did you hear about DYMA? *

What DYMA location are you from? *

New Member

Purcellville (Existing Member)

Brambleton (Existing Member)

What DYMA location will you attend? *

Purcellville

Brambleton

Class Schedule

DYMA Purcellville: Tues & Fri

4:20-5:00 - Intermediate/Advanced (Yellow through Blue/Red belt)

5:00-5:30 - Beginner (White, White/Yellow belt) (Trial class available)

5:30-6:10 - High Advanced (Red through All Black belt)

6:20-7:00 - Teen/Adult (All belts) (Trial class available)

Sat

12:00-12:50 - All Belts & Leadership (Family Class)

12:50-2:30 Poomsae Team

Class Schedule

DYMA Brambleton: Mon, Wed, Thurs

3:50-4:20 - Beginner (White, White/Yellow belt) (Trial class available)

4:20-4:50 - Intermediate (Yellow through Green belt)

4:50-5:20 - Advanced (Green/Blue through Blue/Red belt)

5:20-6:00 - High-Advanced (Red through All Black belt)

6:00-6:30 - Beginner (White, White/Yellow belt) (Little Dragons Ages 4.5-6) (Trial class available)

6:30-7:10 - Inter/High-Advanced (Yellow through All Black belt)

7:10-7:50 - Teen/Adult (All belts) (Poomsae Team Th 7:00-8:30)

Sat

9:40-10:20 High-Advanced/Black & Leadership

10:20-11:00 All Belts (Family Class)

Payment Options and Info:

Prices ( Based on One Year(Blue Belt) membership) *

Member 1: $190/month (single member price)

Member 2: $171/month (10% discounted price for sibling)

Member 3: $152/month (20% discounted price for 2nd sibling)

Plus registration and Uniform: $100 (new member only)

Free Trial Class: $0.00

Monthly Statement/Billing *

Every month on the 1st

Every month on the 10th

Every month on the 20th

Credit Card Type

Name on Card

Card Number

Expiration Date (mm/yy)

CVV

Parent Signature: *

clear

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 the member 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 the member 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 person from our program.

I agree that any picture taken of the member in connection with Taekwondo can be used by Dragon Yong-In Martial Arts for publicity or promotion without compensation at this or any other time.

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

Yes, I approve of application fee and services.