summer camp registration docs_2015.pdf

8/9/2019 Summer Camp Registration Docs_2015.pdf

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2015 USK Karate Academy Summer Camp Registration

Camper Information

Camper’s Full Name: _________________________________________________________________ Last First Nickname

Birth Date: ___________________ Age____________ Gender: M / F Grade Completed:__________

Parent/Guardian’s Name: ______________________________________________________________ Last First

Address: ___________________________________________________________________________Street Address Apartment/Unit #

___________________________________________________________________________________City State ZIP Code

Day Time Phone: ( ) ______________________ Cell Phone:( )____________________________

Work Phone: ( )______________________ E-mail Address:________________________________ _

Insurance Company ___________________________ Policy No: ________________________

T-Shirt Size (circle one): Child S M L Adult S M L XL

Allergies (food, etc) and ANY other health restrictions that we should be aware of:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

15% off for each additional family member.

Day Camp Information: Choose a session. Check the appropriate box.$99 deposit and $49 registration fee due at registration; Balance due by June 1, 2015

Hours: 9am to 3pm

10 week session

June 8- August 14: $1402.99

Session 1

June 8- July 10: $726.99

________________________________________

Session 2

July 13- August 14: $726.99

_____________________________________

Pick Your Weeks

Single Weeks: $170.99

_______________ _________________

_______________ _________________

Hours: 7am to 3pm

10 week session

June 8- August 14: $1730.99

Session 1

June 8-July 10: $896.99

_______________________________________

Session 2

July 13- August 14: $896.99

________________________________________

Pick Your Weeks

Single Weeks: $210.99

___________________ __________________

___________________ __________________

EXTENDED HOURS: $12 per hour, between 3-6pm

Please check the box if you will need this service during summer camp

___$99 Deposit

___$49 Registra

Balance Due ____


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USK Karate Academy Summer Camp 2015Authorization Form

Child’s Name: _______________________________________________________

List Parent’s names, plus all others authorized to pick up child:

Name:_______________________ Ph number:_______________ Cell:__________________





_____________________________________________________________________________

Emergency Contact other than Parents

Name:_____________________ Ph number:___________________ Cell:_________________

Name:_____________________ Ph number:___________________ Cell:_________________

Yes, my child can walk or ride bike home at _______p.m. each day.No, my child must remain on site until picked up.

My child is permitted to watch PG and PG13 rated movies

Media ReleaseFrom time to time during the program, Ki Energy Enterprises LLC, d/b/a USK Karate Academyfeatures our camps, staff and students to showcase the many and varied types of programs andevents that we have to offer. Articles, photographs, video tapes and other communication tools maybe used in newspapers, on television or radio, USK Karate’s website, Facebook, e-mail blasts, andother social, electronic, and print media.

____ I will not allow my child to be photographed for the purpose explained above.

____ I will allow my child to be photographed for the purpose explained above.

Print Name of Child _________________________________

Parent/Guardian Signature ____________________________ Date_____________

Parent/Guardian Print Name_________________________


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AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

I ______________________________________(Parent/guardian), hereby grant permission for my

son/daughter/ward ______________________________(name) to participate in Ki Energy Enterprises LLC,

d/b/a USK Karate Academy and USK Karate Academy Summer Camp, and any or all field trips during USK

Karate Academy Summer Camp during the summer of 2015. I also authorize the Ki Energy Enterprises LLC,

d/b/a USK Karate Academy to obtain, through a physician of its own choice, any emergency medical care that

may become necessary for my child as a result of an accident or sudden illness.

Allergies, Medications, Special notes: _______________________________________________

Parent/Guardian/Ward Signature ________________________________________________

Parent/Guardian/Ward Print Name_______________________________________________

Date:__________________________________________

Acknowledgement of No Refund Policy

I understand Ki Energy Enterprises LLC, d/b/a USK Karate Academy has a No Refund policy for fees and

charges paid for activities sponsored by them. The only exceptions to this policy will be when an activity is

canceled. No other circumstances or situations will qualify for a refund.

By: ___________________________________ Date:_________________________

(Signature As Parent/Legal Guardian of Child)

Print name as Parent/Legal Guardain __________________________________________

OVER


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RELEASE AND WAIVER

1) In consideration of the permission granted ______________________________ (Child’s Name) by Ki Energy

Enterprises LLC, by and through its d/b/a USK Karate Academy, to participate in the Summer Camp 2015 Program,including field trips that are offered, I ________________________________________(Name of Legal Guardian)hereby agree to sign this Release and Waiver.

Accordingly, I agree to unconditionally release, waive, and discharge, Ki Energy Enterprises LLC, d/b/a USK KarateAcademy and its members, employees, agents, and servants, all hereafter referred to as "releasees," from all claims

and courses of action, that___________________________________________(Child’s Name), adjoin my personalrepresentatives, assigns, heirs, and next of kin, may have for any loss, damage, or injury to person or property, not

caused by negligence, or otherwise of the releases.2) Physical Fitness and Medical History: Parent/Legal Guardian hereby understands and acknowledges that the2015 Summer Camp is physically rigorous and demanding and requires Child to be in good health and physical

condition to participate. Parent/ Legal Guardian hereby affirms that Child is in good physical health, does not

suffer from any physical or medical problem which may affect the ability of Child to participate in the Program, andassumes any and all risks relating thereto. Parent/Legal Guardian hereby understands and acknowledges that KiEnergy Enterprises LLC, by and through its d/b/a USK Karate Academy is relying upon the representations made

herein as to the status of Child’s health, and shall not be held responsible for any injury to Child as a result of any

misrepresentation made as to Child’s health. The Parties agree that Ki Energy Enterprises LLC, by and through its

d/b/a USK Karate Academy is to be immediately notified in writing of any change in Student’s physical andmedical condition which may affect Child’s ability to participate in the 2015 Summer Camp. I certify and warrant

that _________________________________(Child’s Name) is in good physical condition and able to participate inthe above activity or event.

3) Waiver of Liability and Release: Parent/Legal Guardian understands that participation in the 2015 SummerCamp will expose Child to risk of physical injury and Parent/Legal Guardian accepts such risks. Parent/LegalGuardian understands and accepts that during the course of participating in the 2015 Summer Camp, employees oragents of Ki Energy Enterprises LLC, d/b/a USK Karate Academy will be engaged in a course of conduct requiring physical contact with Child and hereby grants full consent to Ki Energy Enterprises LLC, d/b/a USK Karate

Academy for such contact as is required by participating. Parent/Legal Guardian hereby releases, holds harmless,

and indemnifies Ki Energy Enterprises LLC, d/b/a USK Karate Academy, its employees, agents, officers, directorsand shareholders from any and all claims, causes of action, liabilities, demand or suits whatsoever, whether known

or unknown, which may result in any way from: (a) contact with Child; (b) any injury or damage incurred by Childor to Child’s property while on the premises of Ki Energy Enterprises LLC, d/b/a USK Karate Academy, whether

participating in a 2015 Summer Camp or otherwise; and (c) Child injuring another child, business invitee, guest, orotherwise on the premises of the Ki Energy Enterprises LLC, d/b/a USK Karate Academy, whether participating inthe 2015 Summer Camp or otherwise. In the event of any action brought by Parent/Legal Guardian against Ki

Energy Enterprises LLC, d/b/a USK Karate Academy, the Parties hereby agree to submit such action exclusively to binding arbitration, the costs of which are to be totally borne by Child (or Child’s Parent/Legal Guardian). The

prevailing party to any such action shall be entitled to an award of their reasonable attorneys’ fees and costs incurredin such action.

4) Miscellaneous: (a) This document contains the entire Agreement between the Parties. This Agreement cannot bechanged except in writing and any such change must be signed by both Parties to be effective; (b) This Agreement

shall be interpreted under the laws of Florida and any action brought under this Agreement shall be brought inBroward County, Florida.; (c) If any provision of this Agreement is found to be unenforceable by any court of

competent jurisdiction, such provision shall be construed in such a manner to preserve as much of the intent of theoriginal language as possible and shall not effect the validity or enforceability of the remainder of the Agreement; (d)This Agreement shall be construed to have been drafted equally by the Parties hereto.

By:_____________________________________By:_____________________________________Parent or Legal Guardian Printed Name

Date:_______________________________

summer camp registration docs_2015.pdf

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