Registration ONLY Fall Creek After School 2022-23 (no billing)

The Karate School Registration Form

Please fill in the form below
The Karate School in Fall Creek picks up at the following schools:

Fall Creek Elementary

Autumn Creek Elementary

Park Lakes Elementary

Humble Christian School

Autumn Ridge Middle School
Verify Enrolling in:*

The Karate School Fall Creek, 8650 N Sam Houston Pkwy, Humble, TX 77396
Students Name*

First NameLast Name
Start Date*
8/11/20 is the first day of school
Age on 1st day of school*
Date of Birth*
01/01/2000
Male/Female*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent / Guardian Information
Primary Parent*

First NameLast Name
Best Number to Contact*

Area CodePhone Number
Alternate Number

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Parent

First NameLast Name
Phone Number

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

Street Address

Street Address Line 2

CityState / 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 NameLast Name
Address*
Phone Number*

Area CodePhone Number
Relationship
Emergency Contact #2

First NameLast Name
Phone Number

Area CodePhone 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 closest emergency facility, or the facility of their choice.
Physician/Clinic/or Hospital*
Address*

Street Address

Street Address Line 2

CityState / 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

MonthDayYear
Food Allergy: Select one. (below is required by TX Dept of Family & Protective Services)*

My child does not have a food allergyMy child has mild food allergies that does not require an Emergency Plan. I will list the details below. I give permission for my child's allergy to be posted where food is served.My child has a Food Allergy. 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 concent for my child to be transported and supervised by facility's staff:*

on field tripsfrom 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

MonthDayYear

The Karate School Registration Form

Parent / Guardian Information

Emergency Contact / Treatment

Parent Handbook Acknowledgement