Membership Checkout – Shaolin Center of Seattle

Membership Information

You have selected the 2 Week Trial – $40 membership level.

The price for membership is $40.00 now.

Membership expires after 2 Weeks.

Username

Password

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Email Address

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Full Name LEAVE THIS BLANK

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Student’s First Name

Student’s Last Name

Student’s Address 1

Student’s Address – City

Student’s Address – State

Student’s Address – Zip

Pronouns

Birthday

Student’s Phone Number

(Parent’s / Guardian’s phone number if Student is too young for a phone)

Interested In

Emergency Contact/or Guardian Contact – Name

Emergency Contact/or Guardian Contact – Phone

Reason for interest

How did you hear about us?

A guardian’s signature is required for students under the age of 18

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First Name

Last Name

Address 1

Address 2

City

State

Postal Code

Country

Phone

Card Number

Expiration Date

Security Code (CVC)

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(Memberships can be temporarily frozen, but not refunded)