Austin Kenpo Karate Summer Camp 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.


Current Fitness Activities:
Previous Training:		If YES, please describe (include length of training & dates):


Payment
I would like to enroll my child in the following camp dates (please refer to our summer camp schedule for class availability information):
I would like to enroll my child in the following program option:

Upon receipt of your application a representative from Austin Kenpo Karate will contact you with further instruction on making your payments. Please do not send your credit card information to us via email.
I prefer to make my payments via:


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



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, including the following statements:

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.

I understand that I am responsible for a one-time registration fee of $39.95 for the first child and $21.65 for each additional child that I choose to enroll in summer camp and that this registration fee includes the cost of the required uniform.

I understand that prepayment of camp tuition in full is required no later than 2 weeks prior to the first week start date to enroll my child in the summer camp. Drop off time is no sooner than 8:30 AM, no later than 9:30 AM, and will pick up my child no later than 5:30 PM. Ealier drop off times can be scheduled for an additional $20.00 fee per week . Failure to adhere to this requirement could result in an additional $10 fee per incident, per day, and is due and payable immediately. I understand that if I make arrangements to drop my child off at a time earlier than 8:30 AM and arrive more than 30 minutes past the specified time I will incur additional charges. I have read, understand and agree to the terms and curriculum as listed on the camp flyer, this form and/or have discussed them with a representative of Austin Kenpo Karate.

AUSTIN KENPO KARATE, INC. will provide the above course of instruction and any failure on my part or my child’s to participate in the registered camp time within 7 days from the first day that the child is scheduled to attend the Austin Kenpo Karate Summer Camp shall not obligate the studio any further but shall not relieve me of my obligation under this agreement. There shall be no refunds of unused camp time unless written notice is given as outlined in this agreement, no less than 14 days prior to the first day that the child is scheduled to attend the Austin Kenpo Karate Summer Camp. I acknowledge that AUSTIN KENPO KARATE, INC. reserves the right to remove student from camp temporarily and/or permanently due to misbehavior or illness, and that I must make arrangements to pick up my child immediately following such notification. I agree that AUSTIN KENPO KARATE, INC., its owner, instructors and /or affiliated employees may perform first aid, CPR, call for an ambulance, and/or otherwise medically treat or arrange for medical treatment for my child when necessary. In case of emergency I understand and agree that medical treatment or ambulance and/or hospital services may be contacted prior to notifying me. I acknowledge that AUSTIN KENPO KARATE, INC. will transport my child as necessary to and from activities that will be located away from the school and that I will not hold AUSTIN KENPO KARATE, INC., its students or instructors for any accidental automobile liable for any injuries that may occur and assume that the risk associated with such transport is comparable to the risk assumed when normally transporting my child in an automobile. I state that my child is physically fit to take karate and participate in this program. Student further acknowledges the existence of some personal risk in participating in said prescribed course like any physical sport or activity, and is assuming this risk without liability to AUSTIN KENPO KARATE, INC., its students, or its instructors. I understand that if my child has food allergies or other dietary restrictions that I am aware that meals will not be provided by AUSTIN KENPO KARATE, INC. and I must provide my child with all lunches and snacks. I acknowledge that AUSTIN KENPO KARATE, INC. will not dispense medication, prescribed or over the counter, to student other than as described in this agreement for medical emergencies. Student must be able to dispense their own medication(s). This is a contractual agreement; students will be relinquished from their contract if they have a permanent medical injury that would prevent the student from participation in the program. Such relinquishment is subject to submission and approval of written documentation supporting such conditions to AUSTIN KENPO KARATE, INC. The effective date of relinquishment from the student’s contract is the 1st day of the following the date of the submission of a written request accompanied by required documentation, and any refund of payment is solely the discretion of AUSTIN KENPO KARATE, INC and will be prorated. No oral modification of this contract exists unless written in this agreement. I understand and agree to the terms of this agreement.