Summer 2018 Registration Form

The Karate School - Atascocita Summer Registration Form

Please fill in the form below
The Karate School Summer Camp is for kids ages 5-13 years. Our hours are 7am-6:30pm. The Karate School is a Martial Arts School AND a Child Care facility combined. It includes progressive martial arts training as the kids advance in skill. Our Regular field trips are: Movies (bi-weekly), Bowling (bi-weekly) and Skating (weekly). In addition we have other field trips and MANY activities planned for in the school. Feel free to look at our planned Field Trip and Activities schedule. We keep the kids busy with martial arts classes, group games, arts & crafts and STEM activities. They also have free time to participate in 4-square, kicking bags, blocks, legos, read books, etc...

With our Summer Camp, you can pick and choose the weeks you need. We will also offer Drop-in for 1-2 days Prices are:

$190/week for 1 student if registered after May 16th

$360/week for 2 students, if registered after May 16th

$515/week for 3 students, if registered after May 16th

$50/day per child for Drop-In (1-2 days a week) if available

3 Days or more is considered a full week
Enrolling in: *

The Karate School Atascocita, 7021 Atascocita Rd, Humble, TX 77346
Students Name *

First Name Last Name
Start Date *
6/1/20 is the first day of summer
Age *
Must be between 5-13
Date of Birth *
01/01/2000
Male/Female *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent / Guardian Information
Primary Parent *

First Name Last Name
Best Number to Contact *

Area Code Phone Number
Alternate Number

Area Code Phone Number
E-mail *
Primary Parent Address (type SAME, if same as student) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Secondary Parent

First Name Last Name
Phone Number

Area Code Phone Number
Address (type SAME, if same as student)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I authorize the following people to pick up my child: (name & phone #) *
Emergency Contact / Treatment
Persons to contact in case of an emergency, if the parents/guardians can not be reached.
Emergency Contact #1 *

First Name Last Name
Address *
Phone Number *

Area Code Phone Number
Relationship
Emergency Contact #2

First Name Last Name
Phone Number

Area Code Phone Number
Address
Relationship
Authorization for Emergency Medical Treatment

In the event that I can not be reached to make arrangements for emergency medical treatment, I authorize the facility director or person in charge, to take my child to the facility below, or the facility of their choice.
Name of Licensed Physician *
Physician's Phone Number *

Area Code Phone Number
Physician Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Hospital or Clinic *
Hospital/Clinic Phone Number *

Area Code Phone Number
Hospital or Clinic Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
By signing below, I give my consent for necessary emergency medical treatment when my child is in the care of this physician and/or hospital or clinic, or the one taken to by the facility director or person in charge.
Signature *

Clear
Date

Month Day Year
Food Allergy: (below is required by TX Dept of Family & Protective Services) *

My child does not have a food allergy that requires an Emergency Plan I give permission for my child's food allergy to be posted where food is served at The Karate School and where the child spends time. I (the parent) will supply a Food Allergy Emergency Plan signed by the child's health care professional that includes: 1) a list of each food the child is allergic to 2) possible symptoms if exposed to a food on the list 3) the steps to take if the child has an allergic reaction
List any other special problems that your child may have, including any allergies, illness, long term medications, limitations and restrictions. (type NONE if applicable) *
Immunization, vision & hearing *

My Child's immunization, vision and hearing screening records are on file at the school they attend. All immunizations and tb test results are current
Name of school they attend & phone # *
I give my consent for my child to be transported and supervised by facility's staff: *

on field trips from school (during school year)
I give permission for my child to be picked up from school by The Karate School, and attend any planned field trips with The Karate School. I realize that the staff and directors will do everything in their power to protect my child during these trips; however, I will not hold them responsible, and waive all claims against The Karate School (The Davis Karate Schools Inc.) for any accidents that may occur during these times.
Signature *

Clear
Date

Month Day Year

The Karate School - Atascocita Summer Registration Form

Parent / Guardian Information

Emergency Contact / Treatment

Parent Handbook Acknowledgement