Austin Kenpo Karate After School Application

All fields are required. If an item does not apply to you please enter "N/A" in that field.

Student Information
Name:
Address:	City:	Zip:
Date of Birth:	Age:	Gender:
Email Address:
Date of Admission:
Student's School:

Parent Information
Primary Parent/Guardian:	Relationship:
Home Phone:	Work Phone:	Cell/Pager:
Place of Work:	Position:
Other Contact Info:
Email Address:

Secondary Parent/Guardian:	Relationship:
Home Phone:	Work Phone:	Cell/Pager:
Place of Work:	Position:
Other Contact Info:
Email Address:

Emergency Contact/Pick-up Information
(Please list the name of person to contact in the event that parents/guardians cannot be reached)
Name:	Phone:	Relation:
Name:	Phone:	Relation:

The following adults (not listed above) are authorized to pick up my child in the event that I cannot:
Name:	Phone:	Relation:
Name:	Phone:	Relation:
Name:	Phone:	Relation:


Medical/Health Information
In the event that I cannot be reached to provide emergency medical for my child I authorize the instructor or representative of Austin Kenpo Karate to seek medical treatment for my child.

Physician's Name:	Phone Number:
Address:
Insurance Information:

My child is not currently under the care of a family physician and I give permission to have him/her treated at a local emergency room.

Preferred Emergency Room (if possible)

My child’s immunization record is on file at the public school they are attending and all immunization and tuberculosis test are current. All necessary vision and hearing screenings as required by the special senses and communications disorders act are current and on file with their at the public or private school my child is attending.

Please list any problems your child may have such as allergies, existing or previous illnesses, injuries in the past 12 months that merited medical treatment, any medicines prescribed for long term continuous use. Write "none" if this does not apply to your child.


Transportation
I give permission for my child to be transported and supervised from school.
I give permission for my child to attend and be transported to all field trips.

Payment
(Upon receipt of your application a representative from Austin Kenpo Karate will contact you with further instruction on making your payments)
Class selection:
I prefer to make my monthly tuition payments via:

I give permission for my child to attend the after school program offered by Austin Kenpo Karate. I state that my child is physically fit to take karate and understand that the staff and instructors at Austin Kenpo Karate will do every thing in their power to protect my child while in their care. I further acknowledge that Karate is a contact sport and like any other sport I realize that there are some personal risks. I am assuming that risk and hold harmless Austin Kenpo karate its instructors and students while my child is in their care.


By submitting this application I agree that I have read and understand the policies set forth in the operational hand book and agree to the conditions and terms outlined.

Please let us know if you have any additional comments or concerns not otherwise addressed in this application: