DYMA In-Person Class Application

Parent First Name *

Parent Last Name *

Email Address *

Phone Number *

Address: *

Best contact number:

Member Name: 1 *

Member Name 2

Member Name: 3

What location are you from? *

What location will you attend? *

Purcellville

Leesburg

Brambleton

Payment Options and Info:

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

Member 1: In person: $190 (single member price)

Member 2: In person:$171 (10% discounted price for sibling)

Member 3: In person :$152 (20% discounted price for 2nd sibling)

Plus registration and Uniform (new member only)

Monthly Statement/Billing *

Every month on the 1st

Every month on the 10th

Every month on the 20th

Credit Card Type

Name on Card

Credit Card Number

Expiration Date (mm/yy)

Parent Signature: *

clear

Customer Agreement: *

Yes, I approve of application fee and services.