Summer 2018 Registration Form

The Karate School Summer Camp is for kids ages 5-13 years. 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. Take a look at our 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, if space is available. Prices are:

If registered by May 14th

$192/week for 1 student, $197/week if registered after May 14th

$364/week for 2 students, $374/week if registered after May 14th

$521/week for 3 students, $536/week if registered after May 14th

$60/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 Fall Creek, 8650 N Sam Houston Pkwy #140, Humble, TX 77396

Students Name*

First NameLast 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*

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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 #)*

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 facility below, or the facility of their choice.

Name of Licensed Physician*

Physician's Phone Number*

Area CodePhone Number

Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Hospital or Clinic*

Hospital/Clinic Phone Number*

Area CodePhone Number

Hospital or Clinic 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 option (below is required by TX Dept of Family & Protective Services)*

My child does not have a food allergy.My child has a mild food allergy (listed below), but it does not require an Emergency Plan.My child has 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 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-Fall Creek Summer Registration Form

Parent / Guardian Information

Emergency Contact / Treatment

Parent Handbook Acknowledgement