LMA DAY CAMP

DAY CAMP Enrollment Form
Tons of structure !!! Tons of FUN !!!
Student Information
Student Name*

First NameLast Name
Student Address*

Street Address

Street Address Line 2

CityState

Zip Code
Student Birthdate*

MonthDayYear
Gender*

FemaleMale
T-Shirt Size*

Youth SmallYouth MediumAdult SmallAdult MediumAdult Large
Parent/Guardian Information
Parent/Guardian*

First NameLast Name
Primary Phone*

Area CodePhone Number
Alternate Phone

Area CodePhone Number
E-mail*
Enrollment Authority

I have legal authority to enroll this student in the Legacy Martial Arts Summer Camp Program. I accept responsibility for this enrollment.
Enrollment Authority*

Approved
Secondary Parent/Guardian Information

(secondary not required)
Secondary Parent/Guardian

First NameLast Name
Secondary E-mail
Secondary Primary Phone

Area CodePhone Number
Secondary Alternate Phone

Area CodePhone Number
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) / guardian(s) listed above.
Emergency Contact Name*

First NameLast Name
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact Phone Number*

Area CodePhone Number
Relationship*
Additional Names & Numbers may be provided in the box
The following individuals are authorized to pickup the student (optional)
Authorized Pickup

First NameLast Name
Authorized Pickup

First NameLast Name
Additional Names may be listed in the box
Medical Information
Authorization for Emergency Medical Treatment

In the event that I cannot be reached to make arrangements for emergency medical attention, I authorize the staff of Legacy Martial Arts to seek emergency medical treatment.
Medical Treatment*

Approved
Please list any special medical conditions, previous serious injuries or regular medications (type NONE if applicable)*
None
Doctor or Urgent Treatment Center Information

In the event of a medical emergency when parents / guardians can not be reached, we must have access to medical history for the student in order to provide access to this information for EMS.
Doctor or Emergency Facility Name*
Phone Number*

Area CodePhone 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.

Legacy Martial Arts does not require their staff to have specific immunizations / vacinations at this time.
Immunizations & Vision and Hearing Screenings*

Validated
Weekly Enrollment
Week selection and enrollment

Please select the weeks your student(s) will be attending.

By selecting any given week you are approving your student's participation in scheduled activities. This includes all planned Field Trips.

Please notify the Director in writing prior to an activity that your student can not participate in.
Available Weeks*

Week #1 (March 10th-14th)
Registration Fee
Weekly Pricing
Current And New Students $120/Week
Summer/Day Camp Operational Policies Document
I have read and acknowledge the content of the "Summer Camp Operational Policy Document".
Waiver & Financial Obligations
Transportation

I am giving permission for the student listed on this form to be transported to/from Summer & Day Camp activities.
Transportation*

Approved
Liability Waiver

I am giving permission for the student listed on this form to participate in the Legacy Martial Arts Summer Camp Program. I realize the staff and instructors 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 LMA Karate for any accidents that may occur when the student is in their care. I also acknowledge that LMA Karate does not provide medical insurance coverage for accidents.
Liability Waiver*

Approved
Financial Obligations

I agree to all financial obligations related to my student's attendance in the LMA Karate Summer/Day Camp. These obligations are defined in the Summer Camp Operational Policies Document .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
Options*

Credit CardACH / EFT Bank TransferCash / Check
Final Step !!!!
Final Enrollment Step

To finalize 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. This can be done the first week your student attends camp (does NOT have to be done prior to that).

HOWEVER, your registration fee must be paid before your enrollment will be processed (and your spot in camp reserved).
Signature

Clear

Type a question

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1 is Worst, 5 is Best

DAY CAMP Enrollment Form

Student Information

Parent/Guardian Information

Secondary Parent/Guardian Information

Emergency Contact / Pickup Information

Medical Information

Doctor or Urgent Treatment Center Information

Immunizations & Vision and Hearing Screenings

Weekly Enrollment

Registration Fee

Weekly Pricing

Summer/Day Camp Operational Policies Document

Waiver & Financial Obligations

Final Step !!!!