M & A Youth Athletics Forms

M & A Youth Athletics - Client Data

1125 South Leroy, Independence, MO 64050
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
MaleFemale
BeginnerIntermediateFighter
Date of Birth

MonthDayYear
Date
EMERGENCY CONTACT
Name

First NameLast Name
Relationship
Phone
Please enter a valid phone number.Format: (000) 000-0000.
USA Boxing Hold Harmless Waiver
Printed Name Parent/Guardian*
Waiver Details
In consideration for my being allowed to participate in boxing activities at M&A Youth Athletics, I hereby acknowledge that such activities (and the gathering of people in public generally) include many risks, known and unknown, and that I hereby accept and assume all risks associated with such activity. I further agree to hold USA Boxing, its member, affiliates, agents, LBCs, directors, employees, volunteers, and other persons associated with USA Boxing harmless from and release them of any liability whatsoever for any and all claims, demands, damages and causes of action of any nature whatsoever related to my participation in those activities.Print and Sign your name below to agree to Waiver Details.
Parent/Guardian Signature*

Clear
Printed Name/Fighter
Signature Fighter

Clear
Date Signed*

MonthDayYear
Date
Credit/Debit Card/ACH Authorization
Authorization Details:

By this authorization, you agree to the regularly scheduled charges to your Credit Card. In each billing period, you will be charged the indicated amount below. You will be provided with a receipt for each payment and the charge will appear on your Credit Card/Bank Statement. In the event the billing date or the amount charged changes, you agree that the notice of such charge will be provided to you at least 10 days before the payment due date. I ____________________________________________, allow M&A Youth Athletics to charge my Credit/Debit Card below for $________ as of _______________, and continue to charge on the same day of the following month. (Add your name and information in the fields below to authorize your payment details.)
Credit CardDebit CardACH
Payment Date

MonthDayYear
Your payments will be charged on the same day of the following month.
Monthly Charge Total
Enter the dollar amount for the charge
Print Name

My Subscriptions*

Beginners Class

$100.00 for each month

Intermediate Class

$110.00 for each month

Fighters Class

$120.00 for each month

Credit Card

Authorized Signature*

Clear
Should be Empty:

M & A Youth Athletics - Client Data

EMERGENCY CONTACT

USA Boxing Hold Harmless Waiver

Credit/Debit Card/ACH Authorization

Authorization Details:

Credit Card