SUMMER Karate Kids 1/2 Day Camps
Camp Dates Available:
June 5th - June 9th
June 19th - June 23rd
June 26th - June 30th
Camper/Student Name
*
First Name
Last Name
Birthdate:
*
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Month
-
Day
Year
Date
Camper/Student Name
First Name
Last Name
Birthdate:
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail:
*
example@example.com
Tel:
*
Parent 1 /Guardian 1 Name:
*
First Name
Last Name
E-mail:
*
example@example.com
Tel:
*
Parent 2 /Guardian 2 Name:
*
First Name
Last Name
E-mail:
*
example@example.com
Tel:
List of all known allergies, existing illnesses, previous serious injuries, injuries during the previous 12 months, any medications prescribed for a long term continuous use and any other medical information, if none, list N/A
*
Additional Emergency Contact other than parent:
*
First Name
Last Name
Relation:
Number
*
In the unlikely event that I cannot be reached to make arrangements for emergency medical attention, I authorize the facility director or person in charge to take my child to the following, if possible or physician of their choice. Name of Licensed Physician:
*
First Name
Last Name
Address of Licensed Physician:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Please enter a valid phone number.
Name of Preferred Hospital or Clinic:
*
First Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PLEASE READ AND SIGN WAIVER
WAIVER AND RELEASE OF LIABILITY: Hwa Sun Martial Arts, LLC encourages you and all students to obtain a physical examination from a doctor before using any exercise equipment or participating in any exercise classes. All exercises including the use of weights and use of any and all equipment and apparatus designed for exercising shall be at the student’s sole risk. In consideration for the attendance and participation in the martial arts training offered by Hwa Sun Martial Arts, I, the student/parent or guardian, acknowledge the existence of certain inherent risks in this type of training and hereby agree to assume all risks. I further relieve the school, its services and management, assigned staff and fellow students from any liability resulting from loss, whether personal belonging or bodily injury. Hwa Sun Martial Arts LLC shall not be liable to student for any claims, demands, injuries, damages, or actions arising due to injury to student’s person or property arising out of or in connection with the use by student of the services, facilities, and premises of Hwa Sun Martial Arts LLC. Student hereby holds Hwa Sun Martial Arts LLC, its officers, owners and employees harmless from all claims which may be brought against them by student or on student’s behalf for any such injuries or claims. I also hereby state that I or my child is physically fit to take the prescribed course of instruction and do so of my own free will in exchange for agreed upon fee. I understand there is no refund policy on any money I pay to Hwa Sun Martial Arts.
RELEASE OF LIABILITY
*
Approve
Photo and Video Release:
Hwa Sun Martial Arts, LLC and those working under their direction are hereby granted permission to take photographs and videos of me and my minor student and use in brochures, websites, posters, advertisements, and other promotional materials Hwa Sun Martial Arts, LLC creates. I also acknowledge that Hwa Sun Martial Arts may have video surveillance on premises.
*
Approve
Date:
-
Month
-
Day
Year
Date
Signature:
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Karate Kids 1/2 Day Summer Camp
June 5th - June 9th
$
175.00
Quantity
1
2
Karate Kids 1/2 Day Summer Camp
June 19th - June 23rd
$
175.00
Quantity
1
2
3
4
5
6
7
8
9
10
Karate Kids 1/2 Day Summer Camp
June 26th - June 30th
$
175.00
Quantity
1
2
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