Private Lessons: Sign Up Form
Fill out this form to schedule a private lesson. 

Lesson Fees: 

1. 30 minutes
2. $45.00/student
3. $25.00 per additional student

1. 60 minutes
2. $80.00/student
3. $35.00 per additional student


Tuition must be paid prior the classes to reserve a guaranteed space.


Refund policy:
1. Private lessons are non-refundable. However, can be rescheduled.
2. For any reasons you need to cancel a scheduled private lesson, please contact us at least 24 hours in advance. We will reschedule your lesson at no charge, or $35.00 will be charged for "no show".


Release of Liability Waiver
Please read carefully before checking the checkbox.

USA Shaolin Xiu Culture Centre "The Center" is committed to conducting its activities in the safest manner possible. We hold the safety of the participants in the highest possible regard. Parents must recognize however that there is an inherent risk of injury when choosing to participate in recreational activities. The Center continually strives to reduce such risks and insists that all participants follow safety rules and instructions, which have been designed to protect the participant’s safety.

In consideration of The Center accepting myself or my child into participation and/or training in KungFu/TaiChi/Qi Gong, which activity I hereby acknowledge involves greater than normal risk of injury. I agree, for myself or as my child's parent/guardian to assume responsibility for all risks, cost, or losses sustained by me, my child, or my child's family in connection with participation in KungFu classes, programs, private lessons, or any other activities connected with The Center.

I give my permission to The Center and/or appropriate medical facility to make whatever emergency (first aid, disaster evacuation, etc.) measures as judged necessary for the care and protection of me or my child while under the supervision of The Center.

In case of an emergency, I understand that I or my child will be transported to an appropriate medical facility by the local emergency unit for treatment if the local emergency resources deem it necessary. Transportation will be at my own expenses.

It is understood that in some medical situations, the staff will need to contact the local emergency resource before the parent, physician and/or other acting on behalf of the parent or family can be reached. Further, I hereby release and agree to hold harmless and to indemnify The Center employees, owners or volunteers from any claims, losses or expenses incurred or on the behalf of me, my child or my child's family.


USA Shaolin Xiu Culture Centre
21732 Provincial Blvd. #100
Katy, TX 77450
832-363-7994

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Email *
Phone Number: *
Student's Last Name: *
Student's First Name: *
Private Lesson  *
Required
Private Lesson Fee *
Required
Additional Student(s) *
Name of additional student(s)
Preferred Day & Time *
Monday, Tuesday, Thursday, Friday 9:00am - 3:00pm.  Wednesday 9:00am - 6:00pm 
How would you like to pay? *
Tuition must be paid prior to the classes to reserve a guaranteed space.
I have read and understand this "Release of Liability Waiver" and I voluntarily affix my name in agreement. *
Tuition must be paid prior to the classes to reserve a guaranteed space.
Required
I hereby certify that the responses provided above are true and accurate to the best of my knowledge. *
Tuition must be paid prior to the classes to reserve a guaranteed space.
Required
Student or Parent/Guardian Full Name *
Please type the full name of student or parent/guardian filling out this form. Student MUST be 18 years of age or older.
Questions / Comments
A copy of your responses will be emailed to the address you provided.
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