Black Belt Center Summer Camp Registration

SUMMER CAMP REGISTRATION
Safety First
- We are licensed by DCF (#C09OR0033)
- CPR/First Aid Certified
- Certified by the Martial Arts Teachers' Association (MATA)
PARENTS(S)
EMAIL ADDRESS
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HOME PHONE
Please enter a valid phone number.
CELL PHONE
Please enter a valid phone number.
WORK PHONE
Please enter a valid phone number.
Other person(s) authorized to pick-up your child
NAME
PHONE
Please enter a valid phone number.
NAME
PHONE
Please enter a valid phone number.
Weeks your child will be attending- Minimum 2 weeks – PLEASE SELECT EACH WEEK

Week 1 June 3-7Week 6 July 15-19Week 2 June 10-14Week 7 July 22-26Week 3 June 17-21Week 8 July 29-Aug 2Week 4 June 24-28Week 9 Aug 5-9Week 5 July 8-12
RATE
NOTES
*A 1 week deposit is required in addition to your registration fee and is applied to your last week (non refundable)*
New: $125 reg fee – non refundable – includes uniform & camp T-shirt & back pack

Current: $80 reg fee – non refundable – includes camp t-shirt

Elite Black Belt Team: $40 (no t shirt inc)

Current 4C: $25 reg fee – includes camp shirt

New 4C: $45 reg fee-inc uniform, tshirt, backpack

You are guaranteed a spot for the reserved week - you are responsible for weekly fee amount of registered weeks-All registration & weekly fees are nonrefundable.
MEDICAL INFORMATION
Family Doctor
Phone Number
Preferred hospital
Other
Allergies
Medications
Is student limited or prohibited from any activities?

YesNo
Explain
Does student swim?

YesNo
To what extent?

BEGINTADV
I hereby authorize the program supervisor to arrange for transportation and treatment of my child. I understand that I am financially responsible for any expenses incurred on behalf of my child in seeking medical attention and providing transportation, and authorize medical attention and providing transportation, and authorize medical personnel to initiate treatment immediately as necessary to my child. I hereby agree to waive any and all claims for personal injury, damage, or other loss that may arise out of my activities at the Black Belt Center and further agree to hold harmless and indemnify the center, its principals, employees, agents and other students for any such injuries or loss>
Signature

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Date

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Date
Field trip permission: I hereby give my child permission to attend all field trips with the Black Belt Karate Center. I understand that scheduled trips are subject to change.
Signature

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Date
This form is effective for one year from the date signed.

To register: Call 407-855-8585 Or by mail: 4516 Hoffner Ave Orlando FL 32812

Include your registration fee – major credit cards accepted
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SUMMER CAMP REGISTRATION

Safety First