2016 ASK SUMMER CAMP ENROLLMENT FORM

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1 2016 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 Address (if different than child) Address (if different than child) 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 / 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.

2 SECTION 4: Dates and Location Attending Summer Camp My Child Will Be Attending Camp At American Sports Karate Located: 2464 Vanderbilt Beach Road Suite 530 Naples, FL Single Days: (List Dates) Weeks: Please Circle The Weeks Your Child Will Participate In Camp. 6/6 (3 day week) 6/13 6/20 6/27 7/4 (4 day week) 7/11 7/18 7/25 8/1 8/8 Notes: 6/6 is a partial week and will be prorated at your established discounted rate but will not apply toward total week accumulation for discount. 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. Geocaching: 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.

3 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 Address (if different than child) Address (if different than child) SECTION 7: PEOPLE NOT AUTHORIZED TO PICK UP STUDENT Must provide copy of court order Notes: Notes: SECTION 8: EMERGENCY CONTACT INFORMATION Notes:

4 SECTION 9: MEDICAL INFORMATION Current Health Issues Medications Allergies Yes / No Physician Phone Health Insurance Policy # Notes SECTION 10: SIGNATURES 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 amount to be charge to my above payment method or if that method is not working, any other method American Sports Karate may have on file at that time. Print Name Signature X X TERMS AND CONDITIONS OF ENROLLMENT IN SUMMER CAMP 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. Summer Camp Program Prices: I will be prepaying in full the total. non-refundable amount of: $ I will be paying each Friday prior to the weeks my children attends

5 Uniform: No Additional Charge with Sign Up Registration Fee $0 /one time Daily Camp Attendance: $60 per day 1-3 week: $ weeks: $225 per week 6 7 weeks: $205 per week 8 10 weeks $185 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 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 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 $ PAYMENT AND PICK UP INFORMATION 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 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.

6 PARENT S RESPONSBILITY CHECKLIST 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 four-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 do not send your child to camp with money and expect that our staff will have time to shop for your child s lunch. If your child does not have a proper lunch and snack food for their time in camp, you will be called and asked to return with the necessary lunch and snack for your camper. 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 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 and Teachers. 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.

7 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

8 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. Furthermore, 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

9 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

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