WORLD KARATE STUDIO
Client Packet
Revised: 2018
BUZZ MINGIN, PH.D.
135 A Eayrestown Road, Southampton, NJ 08088
PHONE: 609-261-1022
www.worldkaratestudio.com
Directions to Dr. Buzz's Office and Karate Studio
135 A Eayrestown Road, Southampton, NJ
PLEASE FOLLOW THESE DIRECTIONS.
DO NOT USE GPS - AS IT MAY DIRECT YOU TO ANOTHER PART OF EAYRESTOWN ROAD
THAT DOES NOT CONNECT WITH OURS.
From Marlton, Medford, Cherry Hill, and Voorhees, NJ
Route 70 East to ¼ mile before the Red Lion Circle. Make a left at the traffic light on Old Red Lion Road. Yorktown Retail and Grove Supply, Inc. will be on the right hand side. Proceed approximately ¼ mile to a stop sign. The Red Lion Inn will be in front of you. Make a left onto Eayrestown Road. Proceed about ½ mile and make a left into the Southampton Industrial Park (look for new steel buildings, beige in color). Kerry Court is on your right. Drive into the parking lot to the back building. We are the far left unit. 135 Eayrestown Road, Unit A.
From Atlantic City, Cape May, and Hammonton, NJ
Atlantic City Expressway to Exit 28 (Route 54/Hammonton). Drive through Hammonton to Route 30 (Silver Coin Diner is on the right at Route 30). Go straight crossing over Route 30 and proceed on Route 206 North. Proceed to Red Lion Circle. Go ¾ of the way around the circle to Route 70 West. Beneficial Bank will be at the intersection of Route 206 and Route 70. Make first right onto Eayrestown Road. Proceed about ½ mile and make a left into the Southampton Industrial Park (look for new steel buildings, beige in color). Kerry Court is on your right. Drive into the parking lot to the back building. We are the far left unit. 135 Eayrestown Road, Unit A.
From Pemberton, Columbus, or North Jersey
Route 206 South to the Red Lion Circle. Make a right onto Route 70 West. Make first right onto Eayrestown Road. Proceed about ½ mile and make a left into the Southampton Industrial Park (look for new steel buildings, beige in color). Kerry Court is on your right. Drive into the parking lot to the back building. We are the far left unit. 135 Eayrestown Road, Unit A.
From Burlington, NJ
Route 541 towards Mt. Holly. Turn right onto the Mt. Holly Bypass/541 Bypass towards Route 38. Cross over Route 38, pass Lowes on the right and continue to the traffic light. Cross over Main Street to stop sign. Turn right onto Eayerstown Road. Follow straight on Winding Road to traffic light (Church Road). Go straight through the light for approximately 2.5 miles until you come to 135 Eayerstown Road, Unit A. Drive into the parking lot to the back building. We are the far left unit. 135 Eayrestown Road, Unit A.
BUZZ MINGIN, PH.D.
135 A Eayrestown Road, Southampton, NJ 08088
609-261-1022
www.worldkaratestudio.com
WORLD KARATE STUDIO
INTAKE FORM
Date:______
Student’s Name:______Nickname:______
Parent’s Name(s):______
Address: ______
______
Email Address (print clearly): ______
Phone Numbers: (H)______(C)______(Alt C)______
Age:______Grade:______
List any disabilities (i.e., ADHD):______
List any medications you or your child takes and how much: ______
Areas of improvement needed (i.e., Anger Management): ______
What are your goals for your child or self in attending Buzz’s karate?
Has your child ever attended any of Dr. Buzz’s Social Skills Sessions in the past?
______Yes ______No If yes, when, what date, or time period was it? ______
Any other information that you can provide to help us understand you or your child better:
How did you hear of Dr. Buzz’s Social Skills Karate Program?
Please charge my Credit Card. I have enclosed cash.
I understand my credit card will automatically be charged
for each new karate cycle unless I cancel in writing. Amount______
Credit Card #______Billing Address:______
Exp. Date______Security Code______
Cardholder’s Signature: ______
______
BUZZ MINGIN, PH.D.
135 A Eayrestown Road, Southampton, NJ 08088
609-261-1022
www.worldkaratestudio.com
WORLD KARATE STUDIO CLASS DESCRIPTIONS
BBC - Beginner Behavioral Class: Social Skills Karate for 4 to 12 year olds. Class is behavior modification based with small group instruction. The class is taught utilizing differentiated instruction and positive reinforcement. Although the design of the class is a self-contained concept, the instruction is structured in a proactive manner to allow for social interaction, utilization of taught coping skills, and accountability for student decision making. This class is held Mondays and Thursdays, 5:30 to 6:30 PM, and Saturdays 9:00 to 10:00 AM.
IIC - Intermediate Integrated Class (Bone Breaking Thunder Clan/Junior Class): Social Skills Karate for 4-12 years, Orange Belt to Blue Belt. The social skills karate is taught in a socially interactive structure. Instruction is not only taught through a differentiated instruction, but also in small group, one-on-one and often in rotations. Behavior modification is maintained for those who need it, as the goal in this class is to integrate students who require support with those who require less or no support in an integrated fashion. This class is held Mondays and Thursdays, 6:30 to 7:30 PM, and Saturdays from 10:00 to 11:00 AM.
AIC - Advanced Integrated Class (Bone Breaking Thunder Clan/Senior Class): Traditional Karate & American Freestyle Hapkido is taught to Blue Belts and higher belts at any age or those who are 13 years and older, any belt color. Full contact karate instruction is taught with a secondary emphasis in social skills interaction. Purple Belts and higher are trained with Bo Staff. All students are trained in other related weaponry, self-defense and full contact martial arts as well. This class is held Mondays and Thursdays from 6:30 to 7:30 PM, and Saturdays from 11:00 to 12:00.
AFH - American Freestyle Hapkido Class: An AFH class that includes traditional Korean Martial Arts and AFH techniques. This class is for mature participants only. Therefore, if you are an adolescent and wish to join, you must get approval from the head instructor in order to attend. This class is designed for serious participants only, Blue Belts and up who are ages 14 and up, or anyone age 18 and up at any belt color. Karate uniforms are not necessary for this class. Sweats, shorts, t-shirts, Under Armor, etc. would be most beneficial. This class is available to anyone enrolled in karate who meets the age and belt restrictions. This class is held Mondays and Thursdays from 7:30 to 8:30 PM, and Saturdays from 12:00 to 1:30.
WORLD KARATE STUDIO
135 A Eayrestown Road, Southampton, NJ 08088
609-261-1022
www.worldkaratestudio.com
TESTING FEES
Yellow Belt $60.00
Yellow Belt with Stripe $65.00
Orange Belt $70.00
Orange Belt with Stripe $75.00
Green Belt $80.00
Green Belt with Stripe $85.00
Blue Belt $90.00
Blue Belt with Stripe $95.00
Purple Belt $100.00
Purple Belt with Stripe $150.00
Red Belt $200.00
Red Belt with Stripe $250.00
Brown Belt $300.00
Brown Belt with Stripe $350.00
Black Belt $400.00
2nd Degree Black Belt…………………………………………………………………...$500.00
3rd Degree Black Belt……………………………………………………………………$600.00
4th Degree Black Belt……………………………………………………………………$750.00
EQUIPMENT FEES
· Traditional Karate Uniforms (All uniforms are fully equipped with silk screen and patches):
Size 000, 00, 0, and 1 to 5 $65.00
Size 6, 7 and 8 $85.00
All uniforms include 2 patches and silkscreen.
· Heavyweight Uniforms (All uniforms are fully equipped with embroidering and patches):
Size 4 and 5 $165.00
Size 6, 7 and 8 $185.00
· Karate Belts Size 000 – Size 5 $7.00
· Karate Belts Size 5 – Size 8 $8.00
· Head, Hands & Feet Gear w/Mouth Piece $75.00
· Mouth Pieces $5.00
· Karate Equipment Bags $55.00
· Headbands $15.00
· AFH Patch $15.00
· 3 Flags Patch $15.00
· T-Shirts (Kid small to adult medium) $15.00
· T-Shirts (large & XL) $20.00
· T-Shirts (2XL & 3XL) $25.00
· Embroidered Colored Belts $30.00
· Embroidered Black Belts $55.00
MEMBERSHIP FEE SCHEDULE
$1,900: 1 year membership, full time. This includes a “Hopper Pass”. The Hopper Pass allows students to attend both World Karate Studio locations at any scheduled times, Southampton and Medford. For example, a student who is full time, with a Hopper Pass is able to attend the Medford location on Monday’s and Thursday’s classes and then attend the Southampton location for Saturday classes as well…or any combination of the same.
$350.00: 2 months, a full-time student. Mondays, Thursdays and Saturdays. This includes a Hopper Pass. The Hopper Pass allows students to attend both World Karate Studio locations, Southampton and Medford. For example, a student is able to attend Medford location on Monday and Thursday’s classes and then attend Southampton for Saturday classes as well…or any combination of the same.
$250.00: 2 months, 2 times a week. Students are able to attend a chosen location, Southampton or Medford, Mondays and Thursdays at regularly scheduled times.
$200.00: 2 months, full time membership for parents of students who attend. Parents are offered a Hopper Pass if one’s child/student is full time Hopper Pass student.
$175.00: 2 months, one time a week. Students are able to attend a chosen location, Southampton or Medford, one day a week at any regularly scheduled time.
$25.00: Drop in, any one day participation at a regularly scheduled time at either location on any appropriate and preapproved scheduled karate class time(s).
Sibling Discounts: A 10% discount is deducted from the tuition for any sibling who joins.
For families with 3 or more members participating, a 10% discount will be taken from the total
All payments can be made by credit cards and/or cash. There are no reimbursements for any student who commits to a cycle and then quits or does not return for any reason. Martial art equipment, uniforms, shirts, head bands, boards and other breaking materials, testing fees, etc. are not included in the tuition charged for instruction.
Any parent of a karate student who is enrolled in the karate cycle who wishes to participate in karate as well, the cost for each parent is $200.00 for the cycle. Your child/children must be enrolled in the karate cycle as well.
This fee schedule is subject to change without notice
BUZZ MINGIN, PH.D.
135 A Eayrestown Road, Southampton, NJ 08088
PHONE: 609-261-1022 www.worldkaratestudio.com
SOCIAL SKILLS KARATE AGREEMENT
THIS AGREEMENT made and executed this ______day of ______, 20_____ by and between: DR. GERALD “BUZZ” MINGIN/WORLD KARATE STUDIO/BUZZ’S BOOKWORM, INC. (hereinafter referred to as “Service Provider” and ______, the Parent(s) and Guardian(s) of, ______, hereinafter referred to respectively as the “Parent/Client” and/or “Student/Client”.
1. PAYMENT FOR SERVICES: Payment for services is due by the first day of each program start date via cash, check, Visa, MasterCard, Discover or American Express. The entire balance is due and owing for this entire servicing period regardless of how often the student/client participates. Services rendered will be charged in accordance to the advertised “Fee Schedule.” The client’s credit card will automatically be charged for every new karate cycle without notice unless the client provides an email to the Service Provider stating the student/client no longer wishes to continue in the karate program for the new cycle or wish to change their payment method to cash. Should the Parent/client plan to pay by cash or check, a credit card is necessary to have on file before services can be provided. It is understood and agreed upon that the Fee Schedule may change at any given time without notification. A 10% discount will be given for any sibling who joins. A 10% discount will be applied to the family’s entire balance if 3 or more members join at once. We will prorate students who join after the start of a new session. For those students who wish to bring a friend, an agreement must be completed by the friend’s parent/guardian first and a fee of $25.00 will be charged to the visitor. Parent/client will be expected to pay for their own related martial arts equipment and resources, i.e., t-shirts, uniforms, headbands, sparring equipment, boards, promotional belt tests, etc. that are recommended and built into the karate program’s system of awards.
2. LATE PAYMENTS: If payment is not made, Service Provider will withhold services until the balance is fulfilled. Should a payment extend over thirty (30) days past the initial attended karate class of each cycle, a $25.00 charge will be added to the balance each cycle. If the balance goes unpaid beyond sixty (60) calendar days, Service Provider reserves the right to file a claim with a Court of appropriate jurisdiction and the parent/client shall be responsible for interest, costs of suit and reasonable attorney fees.
3. REIMBURSEMENTS FOR SERVICES: There are no reimbursements for services not attended. There are no reimbursement for any student/client who commits to a cycle and then quits or does not return for any reason.
4. INCLEMENT WEATHER/HOLIDAYS, CANCELLATIONS AND MISSED CLASSES: Classes will not be made up for inclement weather and/or holidays. All cancellations due to inclement weather will be indicated on the world karate studio voice mail by 12 am the day of as well as an email will be sent out to all parent/clients as well. Should a student miss a class due to personal reasons, the Service Provider is not responsible for providing any make up classes for the student/client.
5. RECEIPTS: All clients have the opportunity to receive a copy of their bill when needed via email. For a copy of a bill that includes more than one week, clients must email in advance and request a copy of the bill.
6. DISCLAIMER AND WAIVER: Service Provider disclaims any liability to the student/client or parent as a result of any injury suffered by the student/client while under the instruction of Service Provider. The parent/client understands that the student/client is assuming the risk of injury when engaging in any of the physical activities offered by Service Provider, including but not limited to weight lifting, karate (training, karate testing, tournaments, sparring, board breaking, self-defense training, etc.), wrestling, football, basketball, baseball and all other forms of personal fitness, training or physical activity. It is understood, Service Provider engages in physical contact and physical conditioning, which may be considered rigorous and strenuous to the student/client. It is also understood that under no circumstances will Service Provider be liable for injuries incurred by the student/client while engaging in any of the aforesaid activities or while on the premises and/or under the instruction of Service Provider off the premises at any Service Provider functions or programs. By signing the within Agreement, the parent/client and student/client waives any claim they may have against Service Provider as a result of injuries suffered while on or off the premises of Service Provider. Furthermore, the parent/client and/or student/client assumes full responsibility and assumption of the risk for any injuries suffered while engaged in any of the aforesaid activities and hereby holds Service Provider harmless for any claims arising out of said injuries. The client also allows the staff of world karate studio to take pictures and videos of client/student participants as well agree to have such content posted on World Karate Studio website, facebook page and/or related social media.