Summer Camp Registration Forms

2015 ASK SUMMER CAMP ENROLLMENT FORM
SECTION 1: STUDENT INFORMATION
Registration Date:___/___/____
Name _____________________________________ DOB ___/____/_____ Age _____
Address ________________________ City_________ State_____ Zip Code________
School Attending Next Year______________________ Grade Next School Year______
Name of Sibling(s) Enrolled _______________________________________________
Notes:________________________________________________________________
SECTION 2: PARENT/GUARDIAN INFORMATION
Name _______________________________ Relationship ______________________
Address (if different than child) ________________________________________________
Home Phone ________________________ Cell Phone _________________________
Work Phone ________________________ Email _____________________________
Name _______________________________ Relationship ______________________
Address (if different than child) ________________________________________________
Home Phone ________________________ Cell Phone _________________________
Work Phone ________________________ Email _____________________________
SECTION 3: How Did You Hear About A.S.K.
Please take a moment to tell us how you found out about American Sports Karate’s
Summer Camp Program. Circle the one that applies or write your own response.
A.S.K. Website / Google / Expo / Drive By / School / Friend / Current Member
Other:_________________________________________________________________
Referred by friend:_______________________________________________________
if you were referred by a friend or someone you know, please let us know so we can properly thank them.
SECTION 4: Dates And Location Attending Summer Camp
My Child Will Be Attending Camp At American Sports Karate Located:
A.S.K North (Airport Rd & Vanderbilt Beach Rd.)
A.S.K. South (Davis Blvd. & County Rd. 951)
Single Days: (List Dates) ___________ ___________ ___________ ___________
Weeks: Please Circle The Weeks Your Child Will Participate In Camp.
6/3
6/8
6/15
6/22
6/29
7/6
7/13
7/20
7/27
8/3
8/10
8/17
Notes: 6/3 is a partial week and will be prorated, but does not count toward total week count for discount.
Drop off and pick up at each location requires a minimum number of registrants per location. In the event
one of our locations does not meet minimum registration requirements, we reserve the right to change the
designated drop off and or pick up location to our other location.
SECTION 5: Electives / Special Interests
Electives: My Child Will Participate in the Following Electives:
Elite Karate Training: Yes / No ………………………………………………… No Charge
This program is designed for Orange Belt students and above and is in addition to regularly scheduled karate
classes. This program may include Kata, Kumite, Kubudo, Tournament Tactics, Self-Defense, Ju-Jitsu and other
martial arts.
Private Karate Lessons: Yes / No …………...$50 for 30 min or $75 for 45 min lesson
This is a great way to ramp up your traditional karate training or focus on tournament specifics like Kumite or Kobudo.
Lego Mania: Yes / No ……………………………………………………………No Charge
This is a fun multi-week program at no additional charge. Campers may bring in their own Lego sets
Beading and Jewelry: Yes / No ………………………………………………… No Charge
This is a fun elective for all ages at no additional charge.
Eco Friendly Gardening: Yes / No …………...………………………………… No Charge
This is a fun, outside elective for all ages at no additional charge.
Pottery: Yes / No ………………………………………….........…….Additional Fee of $40
This is an off-site weekly field trip to Earth and Fire Pottery for any age child that can be signed up for multiple times.
Iron Chef Baked Goods Decorating: Yes / No ………………………..……… No Charge
This is a fun and yummy elective for all ages at no additional charge.
Painting and Crafts: Yes / No …………………………………………...……… No Charge
This is a fun elective for all ages at no additional charge.
Grade Bridging Academics: Yes / No ……………………...………………….. No Charge
This elective helps to maintain academic levels during the summer break.
Private tutoring: Yes / No …………………….......… Additional Fee of $30 per half hour
This elective is for children who may not be performing at grade level and need concentrated help in one or more
subjects. A qualified high school student or adult will provide tutoring.
Note: some electives require a minimum registration to conduct and all electives are subject to change or cancelation.
SECTION 6: ADDITIONAL PEOPLE AUTHORIZED TO PICK UP STUDENT
Identification will be required if person other than parent is picking up student and must be at least 18 years of age
Name _______________________________ Relationship ______________________
Address (if different than child) ________________________________________________
Home Phone ________________________ Cell Phone _________________________
Work Phone ________________________ Email _____________________________
Name _______________________________ Relationship ______________________
Address (if different than child) ________________________________________________
Home Phone ________________________ Cell Phone _________________________
Work Phone ________________________ Email _____________________________
SECTION 7: PEOPLE NOT AUTHORIZED TO PICK UP STUDENT
Must provide copy of court order
Name _______________________________ Relationship ______________________
Notes:________________________________________________________________
Name _______________________________ Relationship ______________________
Notes:________________________________________________________________
SECTION 8: EMERGENCY CONTACT INFORMATION
Name _______________________________ Relationship ______________________
Home Phone ________________________ Cell Phone _________________________
Work Phone ________________________ Email _____________________________
Notes:________________________________________________________________
SECTION 9: MEDICAL INFORMATION
Current Health Issues ____________________________________________________
Medications __________________________ Allergies Yes / No __________________
Physician ____________________________ Phone ___________________________
Health Insurance _________________________ Policy # _______________________
Notes ________________________________________________________________
______________________________________________________________________
SECTION 10: SIGNATURES
_____________________________________ Date ____/____-________
PARENT/ GUARDIAN SIGNATURE
_____________________________________ Date ____/____-________
PARENT/ GUARDIAN SIGNATURE
PAYMENT INFORMATION
EFT: withdraw from checking account, please attach voided check
Bank Name: _________________________________________________________________________________
Payment via Credit Card
Acct No. ___________________________________________________ Exp. ____/____ Security Code _______
I hereby authorize the amounts indicated in this contract to be withdrawn from my checking account or
charged to my credit card account listed above and acknowledge the payments herein are due whether I
use the services at American Sports Karate or not. I also understand and agree that if I choose the weekly
payment option and for whatever reason stop making the scheduled payments, the total remaining balance
becomes due and payable immediately and I hereby authorize that total to be charge to my above payment
method at that time.
Print Name
Signature
X____________________________________________ X_____________________________________________ For your convenience, we offer a pre-­‐payment option or weekly payments. Please indicate with our initials whether you will be paying on the Friday prior to each week your children will be attending or pre-­‐paying. I will be prepaying in full the total. I will be paying each Friday p rior ____ non-­‐refundable amount of: $__________ ____ to the weeks my children attends TERMS AND CONDITIONS OF ENROLLMENT IN SUMMER CAMP
Summer Camp Program Prices:
Uniform: No Additional Charge with Sign Up
Registration Fee $0 /one time
Daily Camp Attendance: $60 per day
1 - 3 week: $225
4 – 7 weeks: $200 per week
8 – 11 weeks: $175 per week
Discounts and Deposits:
Sibling 10%: Siblings must attend the same week to obtain discount.
Sign up a Friend: If you refer a friend who has never been a member of American
Sports Karate and they sign up for summer camp you will receive a $25 credit for
each week they sign up for up to $100.
Registration Deposit: One week’s non-refundable deposit is due upon registration
in order to reserve your children’s space in our summer camp.
A NOTE ABOUT THE UNIFORM AND EQUIPMENT
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The (gi) uniform is to be treated with respect. This shows unity and pride in our school and
oneself. The uniform should be kept clean and neat at all times. Please be sure to put your child’s
name on the inside waistband of the pants and on the inside collar of the top. An American Sports
Karate patch must be affixed to the gi in order for the student to participate in martial arts classes
or tests
Please write your child’s name on all their equipment. American Sports Karate cannot be
responsible for lost or stolen items.
TESTING FEES AND EQUIPMENT
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As in any sport, there are equipment and uniforms to purchase. Karate is no exception! Every
2 - 6 months, depending on your child’s skills and level of preparation, there will be a belt testing.
In order to be eligible to test, you must pay the testing fee at least one day prior to your child’s
testing date; the testing fees start at $45.00.
PAYMENT AND PICK UP INFORMATION
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Automatic payments are processed each Friday for the upcoming week. Method of payment is via
automatic payment with accepted credit cards or EFT check withdrawal.
Pick up time for the Summer Camp program is 6:00 p.m. If you are going to be later than 6:00
p.m. please call American Sports Karate at 239-643-2275 (South location) or 239-260-7451
(North location). There will be a late pick up fee of $20 assessed at 6:15 and $1 per minute
thereafter to cover the costs associated with late pickup. We do not offer extended pick up times
beyond 6:00 pm.
Drop off time for the Summer Camp program is as early as 7:45 am.
_____________________________________ Date ____/____-________
PARENT/ GUARDIAN SIGNATURE
PARENT’S RESPONSBILITY CHECKLIST
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You or an authorized adult must sign your child out of the summer camp program daily!
There will be no financial adjustments for days or weeks not attended unless we receive a
minimum two-week’s notice of the attendance change.
If you receive a multiple week registration discount and then reduce the number of weeks
attended, the discount to the previous and remaining weeks may no longer apply and you will be
retroactively charged the appropriate difference and future payments will be adjusted accordingly.
Check our lost and found weekly if your child has lost any items.
Please send your child to camp with a healthy lunch and enough snacks for two snack times. We
do not provide refrigeration so please send food in an insulated container if necessary. You may
send your child to camp with a water bottle that they may keep filling up via our water fountain.
Please send your child to camp each day wearing athletic shoes. If a child wears crocks or flipflops they may not be able to participate in all activities.
RULES FOR STUDENTS
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Behave and buckle up in the van/car. No Horseplay!
Change into your uniform promptly for class.
Keep your personal items in your cubby, or your backpack.
No running at all when not on the exercise floor.
Use inside voices.
Outside of class time, do not TOUCH, PUNCH, HIT, KICK, PINCH (or any other form of contact)
another student or instructor.
Follow all directions given by your instructors.
No bad language or name-calling of any kind is allowed at any time.
Be respectful at all times to your Parents, Instructors, Teachers and fellow students!
DISCIPLINE POLICY
In order to maintain a safe program, we occasionally find it necessary to discipline a
student. We feel that effective and positive ways of behavior management are:
1. REDIRECTION: We will stop the child and calmly learn what has happened, why and how they see it,
and then suggest other ways of handling the situation. Then, we will redirect their attention.
2. SEPARATION: We will have the child sit quietly apart from the rest of the group and rest for a short
time. This gives them an opportunity to calm down and think about their actions. Then we will explain to
them possible alternative behaviors they may have chosen to avoid the problem. We may also have the
child perform a reasonable athletic activity such as push ups or squats as a behavior modification if
multiple separations are required.
3. PARENT CONFERENCE: If a child’s behavior remains problematic, a parent conference will be held.
If there is little or no improvement in the child’s behavior after the parent conference, termination of
enrollment may become necessary.
4. TERMINATION: Termination of enrollment will be at the sole discretion of American Sports Karate LLC.
_____________________________________ Date ____/____-________
PARENT/ GUARDIAN SIGNATURE
_____________________________________ Date ____/____-________
PARENT/ GUARDIAN SIGNATURE
RELEASE AND WAIVER AGREEMENT
I ________________________________________ am the parent/guardian of
_________________________________________. As parent/guardian, I am entering
into the following Release and Waiver Agreement with American Sports Karate, LLC. I
understand that I am signing this Release and Waiver Agreement in consideration for
and as a requirement of the student participating in any American Sports Karate
activities, classes, self defense clinics, after school programs, seminars or other
functions organized by or associated with American Sports Karate LLC, whether located
at the American Sports Karate facility or other location(s).
For myself individually and as parent/guardian for the student, and for successors, heirs
or assignees and legal representatives, I do now and forever, fully and finally, release,
discharge and waive American Sports Karate, LLC and all of its agents, employees,
instructors, heirs, assigns, insurer, from any and all claims, demands, damages,
expenses, costs, actions or causes of actions known or unknown, past, present or
future for any personal injuries including bodily injury or death, which are alleged to
have arisen out of or resulted from student’s participation in any and all activities
organized by or associated with American Sports Karate, LLC, including but not limited
to, martial arts classes, exercises, drills, and sparring. I understand that participation in
martial arts activities includes a risk of serious personal injury or even death. I know that
martial arts are a contact endeavor, and I understand that I am responsible with the
guidance of the student’s doctor for evaluating the student’s physical condition and
ability to participate in the martial arts classes and/or other activities provided by or
associated with American Sports Karate, LLC. By signing this Release and Waiver
Agreement, I am also stating that the student has the physical ability and health
necessary to participate in martial arts classes.
I further represent that I have authority, as parent and/or guardian, to sign this Release
and Waiver Agreement.
This Release and Waiver Agreement executed this ____ day of _____________, 201__
_________________________________________
Parent/Guardian Signature
_________________________________________
Parent/Guardian Name
AUTHORIZATION AND URGENT CARE WAIVER
I hereby authorize American Sports Karate, LLC., all instructors, staff, employees,
volunteers and agents thereof, to act on my behalf in an emergency requiring medical
attention or any other humane action to myself or to the student. I hereby waive and
release American Sports Karate, LLC., and all of its instructors, staff, agents,
employees, servants, assigns, insurers thereof, and fellow students from all liability for
any injuries or illnesses incurred during any and all activities provided by or associated
with American Sports Karate, LLC. I further release American Sports Karate, LLC, and
all of its instructors, staff, employees, volunteers, fellow students and agents (hereafater
“American Sports Karate LLC”) of any and all liability during rescue, care and/or
assistance of any kind in an emergency or medical situation or in a situation where
there may be a reasonable and foreseeable risk of injury to the student or another
person.
I authorize American Sports Karate, LLC and all of its instructors, staff and agents to
provide immediate reasonable care in the event of an injury to the student and release
American Sports Karate, LLC and all of its instructors, employees and agents from any
and all liability related to the treatment of care. I further understand that any care
provided by American Sports Karate, LLC will be limited to immediate simple first aid
care. Any additional care will be provided for by medical professionals, for which
American Sports Karate LLC retains no liability. I also understand that American Sports
Karate, LLC does not have medical personnel as agents or employees or independent
contractors at the facility, events or competitions. Providing any immediate care will be
at American Sports Karate LLC’s sole discretion and American Sports Karate LLC has
no obligations to provide such care if it finds itself unfit to do so.
I understand that participation in martial arts classes and all other activities provided by
or associated with American Sports Karate, LLC., whether within American Sports
Karate LLC’s facilities or outside, involves physical activity and, as such, carries with it
the risk of injury or death. Should an injury occur during any activity provided by or
associated with American Sports Karate LLC, inside or outside American Sports
Karate’s facility, any and all medical expenses incurred are the sole responsibility of the
participant or participant’s family. American Sports Karate, LLC and its instructors, staff
and agents retain no liability for any and all expenses related to injuries to the
participants. Furthemore, American Sports Karate, LLC retains no liability and makes no
representation as to the quality or type of medical care and services that will be
provided by urgent care and hospital facilities or by any and all of their staff, employees
and independent contractors.
Student Name _____________________________
_________________________________________ Date _______________________
Parent/Guardian Signature
PERMISSION TO RIDE FORM /AUTHORIZATION OF TRANSPORTATION
I hereby authorize American Sports Karate, LLC. to transport _______________, as a
student of American Sports Karate LLC, to and from school, events, functions, and
competitions organized by or associated with American Sports Karate, LLC., and any
other places visited from time to time as deemed reasonable by American Sports
Karate. Furthermore, I hereby authorize American Sports Karate LLC to transport
him/her to medical facilities, including, but not limited to urgent care and hospital
facilities, in case of an injury or an emergency requiring medical attention or any other
humane action.
I hereby represent and warrant that I have the authority to give such permission.
Student Name _____________________________
_________________________________________ Date _______________________
Parent/Guardian Signature
_________________________________________
Parent/Guardian Name