Karate Summer Camp 2017 Student Enrollment

After School Program 2018-2019 Student Enrollment

Student Information
Name *

First Name Last Name
Sex *

Boy Girl

Address *

Street Address
Street Address Line 2
City	State
Zip Code	Country

Grade *
Date Of Birth *
Age *
Primary Phone *
Alternate Phone
E-mail *
Primary Parent/Guardian *

First Name Last Name
Relationship *

Address (If different from student)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Primary Phone *
E-mail *
Secondary Parent/Guardian

First Name Last Name
Relationship

Address (If different from student)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Primary Phone
E-mail

Emergency Contact Information
Emergency Contact Name *
Relationship *
Phone Number *
Emergency Contact Name
Relationship
Phone Number
Authorization for Emergency Medical Attention

In the event that I can not be reached to make arrangements for emergency medical attention, I authorize the facility director or person in charge to take my child to the following if possible, or a physician of their choice.
Authorization for Emergency Medical Attention In the event that I can not be reached to make arrangements for emergency medical attention, I authorize the facility director or person in charge to take my child to the following if possible, or a physician of their choice.

Yes
Name of Licensed Physician *
Phone Number *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Hospital or Clinic *
Phone Number *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

By signing below, I give my consent for necessary emergency treatment when my child is in the care of this physician and/or hospital/clinic
Signature *

Clear
Date *

- Month - Day Year
Date

Additional Information about your child
Please list any special conditions/problems that your child may have, such as allergies, existing illness, previous serious illness, injuries during the last 12 months, any medication prescribed for long-term continuous use, or any other information which caregiver's should be aware of. If not applicable please put "N/A" *
I hereby authorize the facility to allow my child to leave the facility only with the following persons: List names AND phone numbers. If not applicable, please put "N/A" *
My child has permission to be released to the care of his/her siblings under 18 years old. *

Yes No
*

My Child's immunization record, vision and hearing screening are on file at the public school they are currently enrolled at and all immunization and TB test results are current
Name of School where Immunization Records are Held *
School Name & Phone Number *

Acknowledgements
Parent Handbook
Parent Handbook Acknowledgement *

I acknowledge receipt of the operational policies (Parent Handbook) including those for discipline and guidance
I hereby give my consent for my child to be transported and supervised by the faculty's staff: *

From School On Field Trips
I hereby give my consent for my child to participate in water activities ***(Students that DO NOT know how to swim or swim well MUST wear a safety flotation device(ie. life jacket, floaties) on swim days) : *

Swimming Pools Wading Pools Both Swimming Pools and Wading Pools
*

I hereby give permission for my child to be picked up from school by Momentum Karate & Fitness, and attend any planned field trips (Summer Camp and Holiday Care) with Momentum Karate & Fitness. 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 Momentum Karate & Fitness (Momentum Karate Schools, Inc.) for any accidents that may occur during these times
Signature *

Clear
Date *

- Month - Day Year
Date

Billing and Tuition
We offer 5, 3 and 2 day a week option. Once you register your child, we will confirm your selection and days of pickup.

5 Days/Week Tuition:

$95/week - 1 student

$175/week - 2 students

$255/week - 3 students

$330/week - 4 students

3 Days/Week Tuition (pick the days that you want):

$72/week

2 Days/Week Tuition (pick the days that you want):

$52/week

**Weeks are NOT discounted for lack of attendance.
Optional: Please add the following amount a day for prepaid snacks for weeks my child is attending (each snack is $0.50 each) *
Registration Fee - Includes Uniform, T-shirt, and saves your spot! (You will receive an invoice through email shortly) *

$100 - New Student Registration Fee $80 - Existing Student Fee
***You are not being charged at this time - You will receive an email by the next business day containing the invoice for the Registration Fee. Please pay through the Square Invoice Email and save your credit card on file. You must pay the Registration Fee to reserve your spot.***
T-shirt Size *

Terms & Conditions
Billing Agreement
This agreement is between Momentum Karate & Fitness and Customer. Momentum Karate & Fitness will appear on your bank/credit card statement. If for any reason the Draft is not approved, Momentum Karate & Fitness will add $10.00 fee. Momentum Karate & Fitness is not responsible for any bank fees incurred by Customer. I Momentum Karate & Fitness has the right to resubmit returned/declined items without prior notice. If your child is not picked up by 6:00pm, late fees will automatically be charged to the credit card on file.

Member's (Customer's) Right to Cancel
If you wish to cancel this agreement, you must submit a request, IN WRITING, to Momentum Karate & Fitness at least 7 days prior to the next billing date. Written request must be presented to staff and signed off by one of them. Deposits are not refundable. Without a written notice, payments will be drafted.

I agree pictures of my child may be used to promote Momentum Karate & Fitness without compensation.

I have read this agreement and understand that once it is signed by me it is a legally binding and enforceable obligation and I agree to comply with all the provisions, terms and conditions set forth on both sides of this agreement. I acknowledge I have received a copy of this agreement. I agree to pay the Balance Billed set forth in this agreement.

Terms and Conditions

Acceptance of Member

By signing this agreement, Customer agrees to fully and completely comply with all terms and conditions hereof and the Business' rules and regulations. Failure to comply with the Business' rules and regulations is ground for immediate suspension or termination of the Customer and Student.

Momentum Karate & Fitness and those acting under its authority reserve the right to use photographs, videotapes, artwork or other likenesses of the Customer and/or Student for marketing, trade, publishing or any other lawful purpose. Customer and/or Student understand and agree that full payment of tuition is not a guarantee or promise of advancement.

Classes

Scheduling and content of classes and programs, furnishing of facilities and provision of instructors to teach and supervise classes and practice sessions are at the sole and absolute discretion of Momentum Karate & Fitness and may be changed at any time by Momentum Karate & Fitness. The Customer understands and agrees that examination/testing fees may not be included in the price of this agreement.

Liability waiver and release

The Customer understands and agrees that strict observation of the Business' rules and regulations and the rules and regulations relative to martial arts training, including the use of protective equipment. The Customer understands and agrees that the use of the Business' facilities and the Member's presence at the Business' facility are at the sole risk of the Customer. The Customer understands and agrees that martial arts involves skills and training which include violent and sudden movements and that in connection with the training and instruction, there will be physical contact between instructors and students, and between and among the students that such contact may result in personal injury to the student, despite precautions taken to avoid such injuries. The Customer hereby consents for the student to engage in such contact as may be necessary or required by student's participation in the training program and/or classes.

The Customer, Student and anyone claiming by or through the Customer or Student, hereby holds harmless, releases and forever discharges Momentum Karate & Fitness, Momentum Karate Schools Inc., its officers, directors, and representatives and the business and its instructors, agents, employees, volunteers, operators, and authorized representatives from any liability, claim, loss, including loss of property, damage, personal injury, or expense incurred by the Customer or Student and arising from the Customer's execution of this agreement, payment processing, participation in any program offered by Momentum Karate & Fitness, including, but not limited to any injury or damage caused by the negligence of Momentum Karate & Fitness, the Business, its instructors, Members, agents, employees, operators, or authorized representatives. The Customer specifically understands and agrees that he/she is assuming the risk of any and all injuries that he/she or the Students may suffer or incur as a result of his/her execution of this agreement and participation in any program offered by Momentum Karate & Fitness.

Compliance with Laws

This agreement shall be governed by the laws of the State in which the Business is located. All rights and obligations of the Business and Customer under this agreement are subject to all applicable federal, state and local laws and regulations. To the extent that the terms and conditions of this agreement conflict with any applicable statute, rule or regulation in effect at the time of execution of this agreement governing transactions of the type contained herein, the agreement shall be deemed revised to conform with such statues, rules and regulations. The Business and Customer shall be bound by the modified agreement and agree that no other modifications shall be enforceable unless in writing and signed by the parties. This agreement constitutes the entire agreement between the parties and supersedes all prior agreements between the parties, whether written or oral. The invalidity or unenforceability of any provisions hereof shall not affect the validity of enforceability of any other provision. The waiver of any breach shall not constitute a waiver of any subsequent breach of this agreement.

Default

Non-payment, or declined payment of scheduled payments in excess of 14 days shall constitute default under this agreement. If this agreement is in default, the entire amount owed hereunder shall become immediately due and payable, litigation may be initiated to collect all amounts due, or the account referred to collection. In the event of default in payment or breach of this agreement, Ince Karate shall be entitled to recover their reasonable attorney fees, court costs, and interest on any past due amount at the rate of 1.15% per month.

Signatories

Any person(s) signing this agreement, whether as a Customer, co-signer or otherwise shall be jointly, severally and individually liable to Momentum Karate & Fitness for the full Billing price as if such person signed as the collection, including but not limited to collection agency fees, court costs, attorney’s fees, and late charges that may be incurred in the event of a default.
Signature *

Clear
Date *

- Month - Day Year
Date

Student Name *

First Name Last Name
After School Karate Guidelines

Below are some Guidelines for After School Karate Program. Following these
guidelines will help things run smoother for you & your child. Please read over the
Parent Handbook for a more detailed list of our Operational Procedures.

Hours & Fees
- After School hours are from 3:00pm until 6:00 pm
- All students must be picked up by 6:00 pm. For us to run our Night Classes, it is important that all After School students be picked up on time.
- At 6:15 pm, an additional $5 is due. Each additional 15 minutes to follow will be assessed a $10 fee.
- Late fees will automatically be charged to the credit card on file.
- Students need to be signed out every evening. Sign-out sheets are in the Lobby.
- Tuition is set up for automatic payment with a Debit or Credit Card. If the card is declined, a $10 fee will be added. Discounts are not given for partial weeks.
- Day Camp and extra activities are not included in tuition. Please bring a credit card to pay for these, or sign up to have these added to your tuition automatically.
Food
- Students can bring snacks or purchase something from our snack bar. Cold drinks & most snacks are $0.50 - $1.00 each. Snacks are not provided by Momentum Karate & Fitness If you would like to prepay snacks, you can add it to your credit card payment.
- Students will need to bring a lunch during all day camps unless we notify you ahead of time. *There is NO use of microwave provided for students.
- Thursday is T-Shirt Day. If the student wears a Karate t-shirt to school, they will receive one Free Snack at snack time when we arrive back at Momentum Karate & Fitness.
Karate
- Karate Uniforms are to be brought each Monday, and taken home each Friday, to be washed.
- Students are expected to participate in their scheduled karate class. If they are unable to do so, the parent needs to contact us.
Student Articles
- Students are responsible for keeping up with their belongings. We have a Lost & Found for items that are left.
- Cell phones, iPads, MP3’s or CD players are allowed at Momentum Karate & Fitness but only for a limited time during electronic time.
Communication with the Parents
- Please call Momentum Karate if your child will be absent from school. It helps us plan ahead. You may also text us at 281-882-9342 or 281-763-8594.
- Please keep us updated with your phone numbers. If your child is sick, we must be able to reach you.
- Each student has a file in the front Lobby. We put announcements and any paperwork you need in these files. Please check this folder on a regular basis.
- We like to send reminders to the parents via Email. Please provide us with the best email address to reach you.
- Events and activities are usually posted on our Facebook page or Website.
- Please sign up for our Remind in case there are last minute announcements. Text @momentum24 to 81010 (messaging rates may apply)
Signature *

Clear
Date *

- Month - Day Year
Date

After School Program 2018-2019 Student Enrollment