Student information update form

Only complete the information that requires updating. Thank you.

Member information

Student Name

First Name

Last Name

Contact / Parent / Guardian name (if student under 18yo)

First Name

Last Name

Cell phone (primary contact person)

(update only if different than on file)

(###)

###

####

Email

(update only if different than on file)

Home address

(update only if different than on file)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Payment information

Name on credit card / legal cardholder name

First Name

Last Name

Credit card number

Credit card expiration date (format example: March 2020 is 03/20)

Credit card security code (3 digits MC / Visa back, 4 digits AMEX front)

Billing Address (at least enter zip)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What is your current monthly tuition date?

5th

15th

25th

Message / special instructions:

By checking here you agree this information is true and correct and that you are the legally authorized cardholder pertaining to the information above and are also the responsible party permitted to provide said information in order to complete this form.

Student / Responsible Party name

Entering your name serves as your signature and authorization for LEVEL 3 Martial Arts Performance to update and apply the information above to your membership agreement.

First Name

Last Name

IN-PERSON ONLY (when required): Member / Legal Guardian / Authorizing Party Signature