Student Information
School Address
Parent Information
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Emergency Contact/Pickup Information
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Operational Policy Acknowledgment
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.
Austin Kenpo Karate Student Enrollment Form (Cont’d)
Transportation
Liability Waiver
Austin Kenpo Karate Student Enrollment Form (Cont’d)
Emergency Medical Information and Immunization Records
Family Physician Contact Information
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.
Medical History
Automatic Credit Card Billing Authorization Form (Merchant #64959781)
Program Rates (Check One):
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Method of Payment (Please refer to the Operational Policies for rates and fees):
Credit Card:
Authorized Amount :
Recurring Monthly Withdrawal Date (Check One):
Cardholder Address:
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Methods to Submit Student Application Form (ALL pages):
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):
How did you hear about us? (Check all that apply)