radKIDS Camp Detailed Registration Form

radKIDS Name

First NameLast Name

Birth Date

MonthDayYear

Gender

MaleFemale

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name

First NameLast Name

Cell Number

E-mail

example@example.com

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Why We Collect Medical & Emergency Information
Your child’s safety is our highest priority. The information you provide on this form allows the Nassau County Coalition for Community Health and the radKIDS® program to prepare for and respond appropriately to any medical needs, allergies, or special accommodations that may arise during camp.

This information will be used only by program instructors and authorized staff/volunteers to ensure your child’s well-being. It will not be shared outside of the Nassau County Coalition for Community Health or radKIDS®.

Date of most recent medical examination

Has your child or anyone in your child's household been confirmed as COVID positive or with COVID antibodies?

Does your child feel fine, without restriction? If no, please describe.

Has your child ever been hospitalized or treated for an injury? If yes, please describe.

Has your child ever been injured and not received medical attention? If yes, please describe.

Does your child have any current medical conditions for which they are currently being treated? If yes, please describe.

Is your child currently using any prescription medications? If yes, please describe and share if you feel it will affect their safe participation.

Does your child need any special medical support or accommodations in class? If so, please describe.

Does your child have difficulty breathing?

YesNo

Does your child have high blood pressure?

YesNo

Does your child have diabetes?

YesNo

Does your child have any known allergies? If yes, please describe.

How would you rate your childs activity level?

Low/LimitedModerate/AverageAbove Average

Please describe any exercise, activities, or athletic participation your child currently engages in, if any.

Is your child now, or have they ever, been involved in self-defense or martial arts training? If yes, please describe.

My signature below hereby acknowledges to radKIDS®, Inc. and its radKIDS®
Instructor or Instructors: That my son/daughter and I are aware of the physical nature and possible risks of injury incident to taking this practical course in self-defense and personal safety; That he/she is physically fit to participate in this course, involving various physical techniques; and, we realize that such techniques cannot be successfully employed in every situation, and proficiency can only be achieved through continued practice, exercise of good judgment, and a person’s natural ability. I also understand that sensitive subject matter will be discussed and is in the Parent’s Manual for my review.

COVID Awareness: We have taken enhanced health and safety measures for you, and all other students and participants in this activity based training environment. In the current times of the day we are aware that the Centers of Disease Control and Prevention has advised us that they believe there is an inherent risk of exposure to COVID-19 exists in any public place where people are present. COVID-19 is an extremely contagious disease that can lead to severe illness and death. According to the Centers of Disease Control and Prevention, senior citizens and guests with underlying medical conditions are especially vulnerable. By participating in this training program you voluntarily assume all risks related to exposure to COVID-19. Let's keep each other healthy and safe.

My signature also releases radKIDS Inc and their certified instructors including the class sponsor and agrees to hold harmless, from any liability for injury that may be incurred as a result of this course, or use of strategies within.
I have read the above waiver and release and I understand that there are physical
activities and skills in this program and I sign it voluntarily.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Date

Signature

radKIDS: Safety Empowerment Camp

Athlete Information