24-25 After School Form

After School Program
Legacy Martial Arts After-School 2024-25
Student Information
Student Name*

First NameLast Name
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Students Birthdate*

MonthDayYear
Gender*

FemaleMale
Student Grade*

Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade
Students School*

Alpha OmegaHuntsville Elem.Huntsville Inter.Huntsville High SchoolSam HoustonScott JohnsonStewart Elem.Mance Park
T-Shirt Size*

Youth SmallAdult SmallAdult LargeYouth MediumAdult MediumAdult Xtra LargeYouth Large
Parent/Guardian Information
Parent/ Guardian*

First NameLast Name
Primary Phone #
Please enter a valid phone number.
Alternat Phone # (Cell#)
Please enter a valid phone number.
Email*
example@example.com
Enrollment Authority

I have legal authority to enroll this student in the Legacy Martial Arts After-School Program. i accept this responsibility for this enrollment.
Enrollment Authority*

Approved
Secondary Parent/Guardian Information

secondary Information is not required
Secondary Parent/Guardian

First NameLast Name
Secondary Primary Phone#
Please enter a valid phone number.
Secondary Alternate Phone# (Cell#)
Please enter a valid phone number.
Secondary Email
example@example.com
Emergency Contact/Pickup Information
At least one Emergency Contact person (NOT a parent or guardian already listed) must be entered. This will be used if we can NOT reach the parent(s) / gaurdian(s) listed above.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone #
Please enter a valid phone number.
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Relationship*
Additional Names & Phone # may be provided in the box
The following individuals are authorized to pickup the student (optional)
Authorized Pickup

First NameLast Name
Phone Number
Please enter a valid phone number.
Authorized Pickup

First NameLast Name
Phone Number
Please enter a valid phone number.
Additional Names and Phone # may be listed in the box.
Transportation
Authorization for Transportation

I authorize Legacy Martial Arts to transport my student(s) from schoolto the Leagacy Martial Arts location. I also approve transportations on school sponsored field trips.
Transportation*

Approved
Medical Information
Authorization for Emergency Medical Treatment

In the event I cannot be reached to make arrangments for emergency medical attention, I authorize the staff of Legacy Martial Arts to seek emergency medical treatment. This includes but is not limited to calling 911.
Medical Treatment*

Approved
Please list any special medical conditions, previous serious injuries or regular medications (type NONE if applicable)
Doctor or Urgent Treatment Center Information
In the event of a medical emergency when parents / guardians can not be reached, we must have acces to medical history for the student in order to provide access to the this information for EMS.
Doctor or Emergency Facility Name*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Immunizations & Vision and Hearing Screenings
The student's immunization record is on file at the public/private school the student attends. All immunizations are current. All necessary Vision and Hearing Screenings as required by the Special Senses and Communication Disorders Act are current and on file at the students school.

At this time Legacy Martial Arts does not require staff members to have specific immunizations or vacinations.
Immunizations & Vision and Hearing Screenings*

Validated
Fees
Registration Fee

There is a $35 non-refundable Registration Fee for Existing students includes

T-Shirt. And $85 for New Students required before enrollment will be accepted

(Uniform, T-shirt and 1/2 off the first week for a total $115) for the first week. There are also fees associated with the martial arts training (Test fees, sparring gear, clinics). These fees only apply when you approve of the purchase/ clinic / belt test, ect.

Please indicate your payment preference below.

Weekly Tution / Monthly 4 Weeks 5 Weeks

Current Students: $60/Weekly $240/Monthly $300/Monthly

Sibiling: $120/Weekly $480/Monthly $600/Monthly

Siblings(3): $180/Weekly $720/Monthly $900/Monthly
Please check off Weekly, Bi-Weekly or Monthly*

$60 Weekly$120 Weekly for Sibling$180 Weekly for Siblings (3)$120 Bi-Weekly$240 Bi-Weekly$360 Bi-Weekly$240 Monthly for 1$480 Monthly for 2$720 Monthly for 3
Acknowledgment of fee Structure*

Validated
Waiver & Financial Obligations
Liability Waiver

I am giving permission for the student listed on this form to participate in the 2024-25 Legacy Martial Arts After School Program. I realize the staff and instrutors will do everything in their power to protect my child when in their care. I will not hold them responsible and waive all claims against Legacy Martial Arts for any accidents that may occur when the student is in their care. I also acknowledge that Legacy Martial Arts does not provide medical insurance coverage for accidents.
Liability Waiver*

Approved
After-School Operational Policies Document
I have read and acknowledge the content of the Legacy Martial Arts After-School 2024-25 Operational Policy Document", also includes our "Discipline and Guidance Policy"

Parents: Please take a moment to read the "After-School Operational Policies" it will answer many of your qestions about our program and how we operate on a daily basis.
Operational Policy Document

Approved
Financial Obiligations
I agree to all financial obligations related to my students attendance in the 2024-25 Legacy Martial Arts After-School Program. These obligations are defined in the 2024-25 Legacy Martial Arts After-School Program Operational Policies Document(available on the Legacy Martial Arts website). I have reviewed this document and agree to the obligations.

Forms are available at the Front Desk to provide Credit Card and ACH Transfer information.
Financial Obligations*

Approved
Payment Options*

Credit CardACH/EFT Bank TransferCheck/Cash
Final Step !!!
Final Enrollment Step

To complete your enrollment, you must physically sign (ink) the "Approved" enrollment form. Your enrollment form will be printed at the Karate School and you will be asked to sign it only once.
Signature

Clear
Should be Empty:

After School Program

Legacy Martial Arts After-School 2024-25

Student Information

Parent/Guardian Information

Secondary Parent/Guardian Information

Emergency Contact/Pickup Information

Transportation

Medical Information

Doctor or Urgent Treatment Center Information

Immunizations & Vision and Hearing Screenings

Waiver & Financial Obligations

After-School Operational Policies Document

Financial Obiligations

Final Step !!!