Fillable Registration

AFTER SCHOOL PICKUP FILLABLE REGISTRATION

Student Information

Please provide the required field.

Student's Address:

Parent Information

Please provide the required field.

----------------------------------------

Please provide the required field.

Emergency Contact/Pickup Information

Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.

1.

Please provide the required field.

2.

Please provide the required field.

3.

Please provide the required field.

4.

Please provide the required field.

5.

Please provide the required field.

6.

Please provide the required field.

7.

Please provide the required field.

----------------------------------------

Please provide the required field.

Student Name:

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.

Please provide the required field.

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.

Please provide the required field.

Transportation

Please provide the required field.
Please provide the required field.
Please provide the required field.

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

Liability Waiver

Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.

Emergency Medical Information and Immunization Records

Please provide the required field.
Please provide the required field.

Family Physician Contact Information

Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.

Medical History

Please provide the required field.
Please provide the required field.
Please provide the required field.

CREDIT CARD BILLING AUTHORIZATION

Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.

Program Rates (Check One):

Please provide the required field.
Please provide the required field.

Five Day: $322.95

Three Day: $268.95

Two Day: $253.95

Please provide the required field.

Five Day: $370.95

Three Day: $304.95

Two Day: $268.95

Please provide the required field.

$168.00

-------

Please provide the required field.
Please provide the required field.

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

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

Please provide the required field.

Credit Card:

Please provide the required field.

MC

Visa

Authorized Amount :

Please provide the required field.
Please provide the required field.
Please provide the required field.

Recurring Monthly Withdrawal Date (Check One):

Please provide the required field.

1st

15th

-----

Please provide the required field.
Please provide the required field.

Check (Initial Payment Only)

Please provide the required field.

Cash (Initial Payment Only)

Please provide the required field.
Please provide the required field.
Please provide the required field.

-----

Please provide the required field.

Methods to Submit Student Application Form (ALL pages):

Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.

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):

Please provide the required field.

Mail (Sent to cardholder address only)

Fax

Please provide the required field.

Email

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

Please provide the required field.

Current student

Internet search engine (Google, Yahoo, MSN, etc.)

Citysearch

Yelp

Other internet review site(s):

Please provide the required field.

Facebook

Yellow Pages

Friend:

Please provide the required field.

Other:


AUSTIN KENPO KARATE

5501 N Lamar Blvd,,

Suite A 225,

Austin, Texas 78751

Phone. 512-459-1806

Email. sifuschroder@gmail.com