Fillable Registration

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Student Information

Student Name:

D.O.B:

Date of Admission:

Student’s School:

School Address

Address1

Address 2

City

State

Zip

School Phone:

Home Room Teacher:

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Parent Information

Parent/Guardian:

Relationship:

Home/Cell Phone:

Work Phone:

Address1

Address 2

City

State

Zip

Place of Work/Business:

Position:

E-Mail Address:

Other Contact Info:

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Parent/Guardian:

Relationship:

Home/Cell Phone:

Work Phone:

Address1

Address 2

City

State

Zip

Place of Work/Business:

Position:

E-Mail Address:

Other Contact Info:

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Emergency Contact/Pickup Information

(Emergency contacts in case parents/guardians can’t be reached. I authorize these individuals to pick up my child in the event that I cannot.

List individuals in the order that you would like for us to call in case of emergency and parent/guardians cannot be reached.)

Please include their address or don’t list them. Child Family Protective services will write me a citation if the address is not listed.

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1.

Name:

Phone Number:

Relationship:

Address1

Address 2

City

State

Zip

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2.

Name:

Phone Number:

Relationship:

Address1

Address 2

City

State

Zip

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3.

Name:

Phone Number:

Relationship:

Address1

Address 2

City

State

Zip

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4.

Name:

Phone Number:

Relationship:

Address1

Address 2

City

State

Zip

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5.

Name:

Phone Number:

Relationship:

Address1

Address 2

City

State

Zip

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6.

Name:

Phone Number:

Relationship:

Address1

Address 2

City

State

Zip

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7.

Name:

Phone Number:

Relationship:

Address1

Address 2

City

State

Zip

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Operational Policy Acknowledgment

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Receipt of After School Program Operational Policies (Check box and Sign). This is a legally binding contractual agreement. It is strongly advised that you thoroughly read the Operational Policies and all contracts, and that you discuss any concerns or questions with the Director, prior to signing and submitting said paperwork.

I have read and understand the policies set forth in the Operational Hand Book and agree to the conditions and terms outlined. No other verbal or written modification of these documents exists.

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Signature of Parent/Legal Guardian

Date

Printed Name

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Austin Kenpo Karate Student Enrollment Form (Cont’d)

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Transportation

(Check all the boxes and sign.)

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I give permission for my child to be transported and supervised from school.

Signature of Parent/Legal Guardian

Date

Printed Name

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Liability Waiver

I give permission for my child

(Print Child's Name)

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 everything in their power to protect my child while in their care. I acknowledge that Austin Kenpo Karate 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 or its students or instructors liable for any automobile accident, nor liable for any injuries that may occur and assume that

the risk associated with such transport and activities is comparable to the risk assumed when normally transporting my child in an automobile. I further acknowledge that Karate is a contact

sport and like any other sport I realize that there are some personal risks, and that I am assuming that risk and hold harmless Austin Kenpo Karate and its instructors and students while my

child is in their care.

Signature of Parent/Legal Guardian

Date

Printed Name

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Austin Kenpo Karate Student Enrollment Form (Cont’d)

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Emergency Medical Information and Immunization Records

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 and/or to administer first aid and/or CPR.

Student's Name

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Family Physician Contact Information

Physician’s Name:

Phone #:

Address:

Insurance Information:

I give permission for my child to be treated at a local emergency room if necessary. Preferred of Emergency Room (if possible):

I give consent to emergency medical treatment as seen fit by Austin Kenpo Karate in the event I cannot be reached or if an emergency does not permit time for Austin Kenpo Karate to reach me first.

My child’s immunization records are on file at the public or private school.

School Address:

Address1

Address 2

City

State

Zip

Phone Number:

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hey are attending and all immunization and tuberculosis tests are current. All necessary vision and hearing screenings as required by the Special Senses and Communications Disorders Act are current and on file at the public or private school my child is attending.

Signature of Parent/Legal Guardian

Date

Printed Name

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Medical History

Please list any medical conditions your child has such as allergies, illnesses, and injuries in the past 12 months that merited medical treatment and any medicines prescribed for longterm

continuous use. Write “none” if this does not apply to your child.

1.

2.

3.

4.

Austin Kenpo Karate Student Enrollment Form (Cont’d)

Automatic Credit Card Billing Authorization Form (Merchant #64959781)

Student Name:

To set up your account for automatic billing, complete the information below. All requested information is required to set up the account. Upon approval, Austin Kenpo Karate will automatically bill your credit card for the total of the

daily rates for August, if applicable, plus registration fee, if applicable, prior to the 1st day of class. Thereafter the tuition amount indicated below will be charged to your credit card on either the 1st or 15th of every month, based on the

option chosen below. The total of the daily rates for June, if applicable, will be charged automatically as well.

All charges will be in accordance with the policies set forth by Austin Kenpo Karate. Your total charges will appear on your monthly credit card statement.

Billing will end either at the date specified by this contract, or when you provide 30-day advance written cancellation via email at: sifu@austinkenpokarate.com, and is accepted via email by Austin Kenpo Karate. You agree to pay, and authorize

Austin Kenpo Karate to charge, the credit card: any and all late, cancellation, and other applicable fees in accordance with policies of the contract/program agreed to at time of enrollment and/or renewal.

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Program Rates (Check One):

Annual Enrollment (Per Month):

Five Day: $355.95

Three Day: $295.95

Two Day: $279.95

Semester-Only Enrollment (Per Month):

Five Day: $408.95

Three Day: $335.95

Two Day: $295.95

First Week of School:

$204.95

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Check here if this is the 2nd child (15% discount applies on tuition only as outlined in the Operational Policies)

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Method of Payment (Please refer to the Operational Policies for rates and fees):

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Credit Card:

MC

Visa

$

Authorized Amount :

Enter payment amount for option checked above (first month’s tuition plus $49.95 registration fee for RETURNING students with uniform, or $79.95 for NEW students without a uniform, due at time of registration).

You authorize Austin Kenpo Karate to automatically debit the card every month (other than August as indicated above), on either the 1st or 15th, for the tuition rate checked above PLUS applicable fees listed in this Operational Policies.

No other agreement exists outside of this contract unless mutually agreed upon, in writing via email or facsimile transmittal. DO NOT write contractual changes on this form; they will be considered null and void.

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Recurring Monthly Withdrawal Date (Check One):

1st

15th

Credit Card Number:

Exp (mm/yy):

CVV:

Cardholder Name:

Cardholder Address:

Address1

Address 2

City

State

Zip

Cardholder Phone Number:

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Check (Initial Payment Only)

Number:

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Cash (Initial Payment Only)

(There is a $25.00 fee for all returned checks. Payment via another method will be due immediately if check is returned, and Austin Kenpo Karate reserves the right to decline payment via check in the future.)

Please note when paying the initial payment by check or cash, subsequent payments must be made using a credit card or debit card (with a Visa or MasterCard logo) that is debited monthly. If paying the initial

monthly payment by a method other than credit card please fill out credit card information on this page but DO NOT check the “credit card” box. We will then only use the credit card information provided for your child’s 2nd and subsequent payments.

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Methods to Submit Student Application Form (ALL pages):

1. Mail completed, signed forms and payment to Austin Kenpo Karate, 5501 N. Lamar Blvd. #A-225, Austin, TX 78751. Must be received by due date as outlined in Operational Policies to

guarantee placement. We will attempt to reach you using the contact information given on this form to acknowledge receipt.

2. Deliver your paperwork in person (necessary for cash payments; optional for all others). Please call us prior to coming in, as instructors are not always available to take your paperwork

and payment from you. We will do our best to work with your schedule.

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If you are mailing your payment and would like to receive a paper receipt prior to the first day of after school pickup, please check which method you would like to receive it (otherwise you will receive your receipt on the first day of class):

Mail (Sent to cardholder address only)

Fax

Fax:

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Email

Email:

Student Name:

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How did you hear about us? (Check all that apply)

Other internet review site(s):

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Facebook

Yellow Pages

Friend:

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Other:

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I have read and understood the policies set forth in the operational handbook and agree to the conditions and terms outlined. No other verbal or written modification of these documents exists.

AFTER SCHOOL PICKUP FILLABLE REGISTRATION

AUSTIN KENPO KARATE

AUSTIN KENPO KARATE