2021 Summer Camp Registration
These forms are required for your children to attend camp.
Lozo Karate offers summer camps for children ages 5-12, with weekly themes and field trips that your kids are going to love!
Camp Sessions, Dates & Field Trips
Camp hours are from 9:00 AM to 3:00 PM. Early drop-off beginning at 7:30 AM and late pick up until 5:30 PM are available at no additional charge. Campers should bring a lunch, 2 snacks and a large water bottle each day of camp. Complete the following online form and one of our courteous staff members will contact you to finalize the registration process. Thank you for choosing Lozo Karate for your summer camp needs!
ATTENTION: Due to COVID-19 precautions, summer camp weeks are being restricted to limited capacity.
Camper's Information
Camper's Name (Child #1)
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Date of Birth
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Children must be at least 5 years of age on the first day of camp he or she attends.
Camper's Name (Child #2)
Date of Birth
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NOTE -
Children must be at least 5 years of age on the first day of camp he or she attends.
Camper's Name (Child #3)
Date of Birth
*
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NOTE -
Children must be at least 5 years of age on the first day of camp he or she attends.
Camper's Name (Child #4)
Date of Birth
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Children must be at least 5 years of age on the first day of camp he or she attends.
Please provide any additional information that you think is important or may affect the camper's ability to fully participate in the camp program.
Parent Information
Parent/Guardian 1
Parent/Guardian - 1
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First Name
Last Name
Relationship to Child
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E-mail
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Cell Phone
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Alternate Phone
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Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Work/School Name
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Or enter N/A if not applicable
Parent's Work/School Phone
Where would you like to be reached while your child is at camp?
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Cell Phone
Work Phone
Alternate Phone
Is there an additional Parent/Guardian you would like to list?
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Yes
No
Parent/Guardian 2
Parent/Guardian - 2
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First Name
Last Name
Relationship to Child
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E-mail
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Cell Phone
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Alternate Phone
Home Address Same as Parent/Guardian 1?
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Yes
No
Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Work/School Name
*
Or enter N/A if not applicable
Parent's Work/School Phone
Where would parent/guardian 2 like to be reached while your child is at camp?
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Cell Phone
Work Phone
Alternate Phone
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Emergency Contacts/Authorized Pickup
Parents cannot be listed as emergency contacts. List the name of at least two individuals who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the studio/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.
Emergency Contact & Authorized Pick-Up #1
Full Name
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First Name
Last Name
Primary Phone Number
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Secondary Phone Number
Relationship to Child
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Emergency Contact & Authorized Pick-Up #2
Full Name
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First Name
Last Name
Primary Phone Number
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Secondary Phone Number
Relationship to Child
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Authorized Pick-Up #3
Full Name
First Name
Last Name
Primary Phone Number
Authorized Pick-Up #4
Full Name
First Name
Last Name
Primary Phone Number
Authorized Pick-Up #5
Full Name
First Name
Last Name
Primary Phone Number
AUTHORIZED PICK UP POLICY: Only the people listed above may pick up your child from camp. No exceptions are made for family members without advanced written notice prior to pick up.
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Type initials above to consent
Please provide the names of persons who are UNAUTHORIZED to pick up your child: (These people are specifically NOT allowed to pick up your camper)
List the FIRST and LAST names of all persons unauthorized to pick up your child.
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Medical / Health Information
Name of Physician or Clinic/Hospital
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Does your child have any food, medication or environmental allergies?
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Yes
No
Allergies? Check all that apply
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Food
Medication
Environmental
Please list and explain any allergies
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0/150
Does your child have a special health or medical condition?
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Yes
No
Please explain
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List any history of hospitalization, outpatient surgery, or previous health concerns that would be needed to assist the staff or medical personnel in an emergency situation.
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Medication
Is there any medication that needs to be administered during the day at camp?
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Yes
No
Check all that apply
Prescription medication
Nonprescription medication
Refrigeration required
Topical product or lotion
Name of medication
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Exact dosage
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To be administered at the following times
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Special instructions and/or directions
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Is there ANOTHER medication that needs to be administered during the day at camp?
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Name of medication
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To be administered at the following times
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MEDICATION POLICY: 1) All medication must be in the original container, labeled by the pharmacy, with the child's name with the dosage, time and quantity to be given. 2) Lozo Karate will not give doses, which are different than the amount labeled. 3) Lozo Karate does not allow non-FDA approved drugs to be administered. 4) Lozo Karate personnel will not cut tablets. Any medication must be cut at home or by pharmacist. 5) Lozo Karate is not responsible for the administration of any type of medication that is not turned into the staff. 6) Lozo Karate staff will do everything possible to support a child in complying with taking medication as directed in the information provided. However, Lozo Karate or staff cannot be responsible for a child's non-compliance.
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Type initials above to consent
MEDICATION AUTHORIZATION & RELEASE WAIVER: I (parent or guardian) hereby give permission for staff of Lozo Karate to administer the medication provided and listed above to my child. I have read Lozo Karate policies regarding the administration of medication and agree to comply. I understand that Lozo Karate is NOT responsible for non-compliance by my child. I further acknowledge the Lozo Karate LLC, its directors, officers, agents, employees and staff shall have immunity from any liability from damages, injuries, allergies, or reactions resulting from the administration of the medication provided.
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Sunscreen & Lotion Policy
Lozo Karate staff will assist in applying sunscreen and/or lotion to children attending camp. I (parent or guardian) understand that this may require the staff member to touch my child's face, shoulders, back, arms, and lower legs. Sunscreen and/or lotion will be applied in the presence of other staff members. I understand that staff will not apply sunscreen/lotion to any child's front torso or upper legs, but will assist and/or direct the child to do so. I understand that no Lozo Karate staff member will be allowed to apply any sunscreen, lotion or ointment to any area that would be covered by a bathing suit for any reason. In the event that any child does not bring sunscreen to activities/camp and conditions warrant it's use, members of Lozo Karate staff will use camp supplies to apply sunscreen as described above.
I have read Lozo Karate sunscreen and lotion policy; as a result, I hereby
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Agree and give permission to apply
DO NOT give permission for staff to apply
I GIVE PERMISSION for Lozo Karate staff to administer sunscreen/lotion to my child(ren). I have read Lozo Karate policies regarding the administration of sunscreen/lotion and agree to comply. I understand that Lozo Karate is not responsible for non-compliance by my child. I further acknowledge that Lozo Karate, it's directors, officers, agents, employees, and staff shall have immunity from any liability from damages, injuries, allergies, or reactions resulting from the administration of the sunscreen and/or lotion provided.
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Type initials above to consent
I DO NOT GIVE PERMISSION for Lozo Karate, it's directors, officers, agents, employees, and staff to assist in applying sunscreen to my child(ren). I further agree to take FULL responsibility to apply sunscreen/lotion prior to arrival of all Lozo Karate activities and/or camps. I relieve Lozo Karate, it's management, owners, assigned staff, officers, agents and employees from any liability resulting from not applying sunscreen and/or lotion.
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Type initials above to consent
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Pricing, Payment, Policies & Procedures
Lozo Karate LLC
SESSION RATES: Weekly (Summer Camp Session, Short 4-Day Week): $160; Sessions 2-8: $195. The daily rate for camps is $50 per day and requires a three (3) day minimum. Field Trip costs , are not included and will be billed weekly to your account. Field trip charge is $15 per week and $15 per day during Session 2 (Field Trip Extravaganza).
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SESSION DEPOSITS: A nonrefundable $25 deposit is required to hold your spot. Deposits paid will go towards weekly camp rate. The balance will be collected on the Monday (7 days) prior to the first day of each camp week your child(ren) will be attending. If the credit card is declined, your child will be removed from the camp roster and your place will be filled from the waiting list forfeiting paid deposit if we are unable to reach you within 24 hours.
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SELECT SESSION DATE ($25 Non-refundable deposit per session / Remaining balance collected seven days before first day of camp)
Session 1 - Jurassic Attack (June 1 - June 4) *Short Week
How many children attending SESSION 1?
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Session 2 - Field Trip Extravaganza (June 7-11)
How many children attending SESSION 2?
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Session 3 - Among Us: Ninja Edition (June 14-18)
How many children attending SESSION 3?
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Session 4 - Nerf Special Ops (June 21-25)
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Session 5 - Galactic Bounty Hunter (June 28-July 2)
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Session 6 - Mat is Lava: Obstacle Course Wk (July 12-16)
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Session 7 - Trick Shot Slime: Water Week (July 19-23)
How many children attending SESSION 7?
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Session 8 - Lego: Brick Samurai Master (July 26-30)
How many children attending SESSION 8?
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Credit Card Information (Name as appears on card):
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First Name
Last Name
Credit Card Number
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FIRST 4 DIGITS of Credit Card #
Credit Card Number
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REMAINING DIGITS of Credit Card #
Security Code
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Expiration Date
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(Example: MMYYYY)
Postal Code
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CAMP HOURS: 9:00am-3:00pm. Free Extended Hours 7:30am-9:00am & 3:00pm-5:30pm.
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Type initials above to consent
FOOD AND SNACKS: I acknowledge that Lozo Karate will not provide food and snacks during the camp, and it is my responsibility to send my child each day with lunch, two snacks and water bottle.
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Type initials above to consent
MINIMUM AGE: I acknowledge that my child will be at least 5 years of age on the first day of camp he or she attends.
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Type initials above to consent
WAVIER & RELEASE: Buyer(s) understands that Student(s) is engaging in physical activity, along with the use of Lozo Karate's facilities, equipment, training and instruction, which can be dangerous and could cause injury. Therefore Buyer(s) assumes all risk of injury to said Student(s). Buyer(s) / Student(s) hereby waives and releases any claim or right to sue Lozo Karate, its employees or agents for injury. Buyer(s) has carefully read this waiver & release and fully understands that it releases Lozo Karate of all liabilities for any injury that may occur. It is always advisable to consult your physician before undertaking a physical activity program, particularly those performed at Lozo Karate. Additionally, I hereby grant and authorize Lozo Karate the right to take, edit, copy, publish, distribute and make use of any and all photos or video taken of my child(ren) to be used in and/or for legally promotional materials and digital communications. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing. I understand and agree that these materials shall become the property of Lozo Karate and will not be returned.
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Type initials above to consent
LOSS/DAMAGE/THEFT: Lozo Karate does not assume any responsibility for the loss, damage, or theft of any property belonging to the Buyer(s)/Student(s) and I agree by initialing above that Lozo Karate and its personnel are not responsible or liable for any such property in the event of loss, damage, or theft on or about the facility.
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TRANSPORTATION RELEASE: I (parent or guardian) give my consent to Lozo Karate, its officers, agents, employees, individuals associated with the organization to transport my child(ren) named above to and from the authorized activities and events.
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EMERGENCY MEDICAL: I (Parent or Guardian) give my consent to Lozo Karate, its officers, agents, employees, individuals associated with the organization or any emergency medical personnel to administer necessary treatment to my child (named above) in the event of an emergency and authorize transportation for child by ambulance if situation warrants. I agree to assume responsibility for the payment of the emergency treatment.
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SICK POLICY: Campers, students, family members, guests, and visitors with fever, cough, sore throat or other flu-like symptoms are not permitted until they have completed a 14 day self-quarantine. People who have traveled to a high-risk area for COVID-19 are not permitted or had contact with a person known to be infected with COVID-19 are not permitted until they have completed a 14 day self-quarantine. Any camper with a fever above 100.4 will not be permitted and will be required to be pick-up immediately.
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COVID-19: I (Parent or Guardian) understand that Lozo Karate has implemented steps and procedures to reduce the risk and spread of COVID-19 in accordance with state and federal guidelines. However, due to the nature of the novel coronavirus, Lozo Karate cannot guarantee any visitor, guest, student or camper entering our facility will not be potentially at risk. By entering our facility, you hereby assume full responsibility and waive all claims against Lozo Karate, its owners, staff, instructors, partners or otherwise, for any and all injuries, claims, medical expenses or damages.
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Type initials above to consent
*Trade In Stock: I UNDERSTAND THAT LOZO KARATE IS A MARTIAL ARTS SCHOOL AND NOT A DAYCARE IN AS SUCH, THEIR STOCK-IN-TRADE IS NOT SUPERVISION AND CARE. THE SUPERVISION AND CARE OF MY CHILD(REN) IS INCIDENTAL TO THEIR PARTICIPATING IN THE PROGRAM AND THAT LOZO KARATE IS NOT ASSUMING RESPONSIBILITY OR THE PROVISION OF DAILY CHILD CARE OUTSIDE OF THE PROGRAM. THE INTENT OF LOZO KARATE IS TO TEACH MARTIAL ARTS PHYSICAL AND PHILOSOPHICAL CHARACTER BUILDING SKILLS.
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DISCIPLINE POLICY: In an effort to provide your child and other students with a safe and fun experience, it is necessary that all students exhibit proper behavior, self-discipline and self-control. Correcting unsatisfactory behavior is time consuming and distracts from providing quality, safe, educational, and fun activities for the rest of the students. If we are unable to control a situation, we will contact the parents first by telephone at or near the disturbance, so that the parent may reinforce (by phone) the requirement that all students enrolled in the summer camp program behave satisfactory and follow instructions fully and promptly. Students that cannot be controlled by verbal commands or that are a constant disciplinary problem will be suspended from the program(s).
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EXTRA CHARGES: I acknowledge that my child must participate in field trips every TUESDAY or THURSDAY. As a result, I agree to a $15 field trip charge to be debited from my account the day of the field trip. I agree to a $15 per day field trip fee for Session 2 (Field Trip Extravaganza) with a maximum charge of $75 for the entire week. Due to COVID-19 and compliance with state regulations, I (Parent and Guardian) understand field trips and destinations are subject to change and/or agree to supplements.
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CANCELLATIONS, REFUNDS & ABSENCES: We understand plans change. Lozo Karate will gladly issue a refund (minus the required $25 deposit) for any cancellation request received in writing more than 14 days before the scheduled session date. No refunds, credits, or transfers are available for sick days or absences for any reason.
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Sign Document
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Date Signed
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Special notes or direction for staff members:
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