Spring Break Camp Registration Form

Spring Break Camp Registration Form

APRIL 3 - 7, 2023
Child's Name

First NameLast Name
Birth Date

MonthDayYear
Date
Gender

MaleFemale
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Additional Child
Child 2 Name

First NameLast Name
Birth Date

MonthDayYear
Date
Gender

MaleFemale
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.

Family Information
Parent 1
Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 2
Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Consent For Pick Up
The following people may pick up my child(ren):

RELEASE OF LIABILTY
By signing below, I hereby warrant that I am the parent or legal guardian of the child(ren) registered, who is(are) a minor. I understand that KICKS TaeKwonDo Academy (JJW & PD Inc.) Summer Camps involve fitness, exercise, swimming, and other sporting and recreation activities, in which my child will be involved, and which involve a risk of bodily or physical injury, whether caused by the actions or negligence of members of KICKS TaeKwonDo Academy, guests, volunteers, other children involved in the camps, or employees of KICKS TaeKwonDo Academy. I understand and voluntarily accept and assume this risk of injury for myself and my child, and agree KICKS TaeKwonDo Academy, its employees, officers, directors, and shareholders will not be liable for any injury including, without limitation, personal, bodily or mental injury, death, economic, monetary or financial loss, or any damage of any nature whatsoever to me, my child or his or her heirs, representatives, or estates occurring at the premises of KICKS TaeKwonDo Academy, while using the facilities and equipment owned or operated by KICKS TaeKwonDo Academy, or while participating in activities or classes, providing or receiving training or instruction, or observing or participating in any way in any fitness, exercise, swimming, or other sporting or recreation activities or events of KICKS TaeKwonDo Academy, or resulting from or in any way arising out of the negligence of KICKS TaeKwonDo Academy, anyone on KICKS TaeKwonDo Academy behalf, or anyone at the premises KICKS TaeKwonDo Academy or using the facilities owned or operated by KICKS TaeKwonDo Academy. I further agree that the foregoing release and waiver of claims and liability is intended to be as broad and inclusive as is permitted by the laws of North Carolina and that if any portion hereof is held invalid, I agree that the balance shall continue in full legal force and effect. I acknowledge that I have read the release of claims and waiver of liability and that I am aware of its legal consequences, including that it prevents me from suing or asserting any claims against KICKS TaeKwonDo Academy or its employees, agents or officers if my child is injured or damaged for any reason as a result of his or her participation in the Summer Camps.
Signature

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PICTURE RELEASE
This release form is for the purpose of putting pictures with students on the KICKS TaeKwonDo Website. The intended use is for promotional segments throughout the site including but not limited to monthly specials, advertisement and/or educational aids for current students.
Select One:

I DO give my permission for KICKS TAEKWONDO's Webmaster and owners to use my child(ren)'s picture(s) on the KICKS TAEKWONDO Website.I DO NOT give my permission for KICKS TAEKWONDO's Webmaster and owners to use my child(ren)'s picture(s) on the KICKS TAEKWONDO Website.
Signature

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Assumption of the Risk and Waiver of Liability Relating to Coronvirus/COVID-19
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. JJW & PD, Inc. dba KICKS TAEKWONDO has put in place preventative measures to reduce the spread of COVID-19; however, JJW & PD, Inc. dba KICKS TAEKWONDO cannot guarantee that you will not become infected with COVID-19. Further, participation could increase your risk of contracting COVID-19.

READ CAREFULLY BEFORE SELECTING EACH PARAGRAPH
Please select in agreement to terms.*

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by participation; and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at KICKS TAEKWONDO may result from the actions, omissions, or negligence of myself and others, including, but not limited to, KICKS TAEKWONDO’s employees, volunteers, and program participants and their families.I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my participation at KICKS TAEKWONDO. On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless KICKS TAEKWONDO, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of KICKS TAEKWONDO, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation at KICKS TAEKWONDO.I represent that I have adequate insurance to cover any injury or illness I may suffer or cause while participating in this activity, or else I agree to bear the costs of such injury or illness myself. I further represent that I have no medical or physical condition which could interfere with my safety in this activity, or else I am willing to assume – and bear the costs of – all risks that may be created, directly or indirectly, by any such condition.In the event that I file a lawsuit, I agree to do so in the state where KICKS TAEKWONDO is located, and I further agree that the substantive law of that state shall apply. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.By signing this document, I agree that if I am exposed or infected by COVID-19 during my participation in this activity, then I may be found by a court of law to have waived my right to maintain a lawsuit against the parties being released on the basis of any claim for negligence.I have had sufficient time to read this entire document and, should I choose to do so, consult with legal counsel prior to signing. Also, I understand that this activity might not be made available to me or that the cost to engage in this activity would be significantly greater if I were to choose not to sign this release, and agree that the opportunity to participate at the stated cost in return for the execution of this release is a reasonable bargain. I have read and understood this document and I agree to be bound by its terms.If I have signed a separate general waiver of liability connected to my participation at KICKS TAEKWONDO, I agree that the terms of that waiver are wholly incorporated into this document and that the terms of this document are incorporated into the separate general waiver.I agree that I will practice safe social distancing and clean hygiene during my participation at KICKS TAEKWONDO.
Signature

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PARENT OR GUARDIAN ADDITIONAL AGREEMENT

Must be completed for participants under the age of 18
In consideration of my registered child(ren) being permitted to participate in this activity, I further agree to indemnify and hold harmless Releasees from any claims alleging negligence which are brought by or on behalf of minor or are in any way connected with such participation by minor.
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Spring Break Camp Registration Form

Additional Child

Family Information

Consent For Pick Up

RELEASE OF LIABILTY

PICTURE RELEASE

Assumption of the Risk and Waiver of Liability Relating to Coronvirus/COVID-19

PARENT OR GUARDIAN ADDITIONAL AGREEMENT

SELECT DATES NEEDED

Payment Methods