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Phone: (941) 544-5572
Alpha Martial Arts Academy
6849 Buffalo Road, Palmetto, FL 34221
(941) 544-5572
NEW YEARS CAMP REGISTRATION
NEW YEARS CAMP REGISTRATION
Dates for Camp:
STUDENT 1 NAME:
(Required)
First
Last
STUDENT’S DATE OF BIRTH:
MM slash DD slash YYYY
STUDENT 2 NAME:
First
Last
STUDENT’S DATE OF BIRTH:
MM slash DD slash YYYY
STUDENT 3 NAME:
First
Last
STUDENT’S DATE OF BIRTH:
MM slash DD slash YYYY
ADDRESS:
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
PARENT 1 NAME:
(Required)
First
Last
PARENT 2 NAME:
First
Last
ADDRESS SAME AS STUDENT:
(Required)
YES
NO, IF SELECTED COMPLETE THE FOLLOWING
ADDRESS:
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
PHONE:
(Required)
EMAIL ADDRESS:
(Required)
EMPLOYER:
EMERGENCY CONTACT:
(Required)
First
Last
EMERGENCY CONTACT PHONE:
(Required)
PLEASE LIST ANY PERSONS AUTHORIZED TO PICK UP YOUR CHILD(REN):
NAME:
First
Last
PHONE NUMBER:
NAME:
First
Last
PHONE NUMBER:
DROP OFF/PICK UP & SIGN OUT INFORMATION:
DROP OFF TIME BEGINS AT 8 A.M.
EARLY DROP-OFF BEGINS AT 6:30 A.M. AT AN EXTRA CHARGE OF $5 PER HALF HOUR.
PICKUP TIME BEGINS AT 5 P.M. UNTIL 6:00 P.M.
LATE PICKUP: THERE WILL BE A LATE CHARGE OF $5 PER 30 MINS. LATE. THIS FEE CAN BE PAID AT THE TIME OF PICKUP OR APPLIED TO THE WEEKLY TUITION. PLEASE CALL TO NOTIFY US IF YOU WILL BE LATE.
PLEASE COME INSIDE THE FACILITY TO SIGN OUT THE STUDENT.
IDENTIFICATION MUST BE SHOWN AT TIME OF SIGN OUT.
IF YOU HAVE SOMEONE OTHER THAN THE USUAL PERSON PICKING UP YOUR CHILD, PLEASE CALL US WITH THAT PERSON’S NAME AND INFORM THAT PERSON THAT THEY MUST HAVE PROPER IDENTIFICATION CLEARLY SHOWING THEIR NAME AND PHOTO. WE CANNOT RELEASE YOUR CHILD TO ANYONE WITHOUT PROPER IDENTIFICATION.
IF THERE IS ANYONE WHO IS NOT LEGALLY ALLOWED TO PICK UP YOUR CHILD, PLEASE MAKE US AWARE OF WHO THEY ARE AND HAVE A COPY OF THE COURT ORDER OR RESTRAINING ORDER FOR OUR FILES.
GENERAL INFORMATION:
PLEASE CALL, EMAIL, OR TEXT US IF YOUR CHILD WILL BE ABSENT. IF THERE IS NO ANSWER, PLEASE LEAVE A MESSAGE.
PLEASE MAKE SURE YOUR CHILD’S NAME IS CLEARLY WRITTEN ON ALL OF HIS/HER PROPERTY/BELONGINGS.
YOUR CHILD CAN BRING A LUNCH, SNACK AND DRINK FOR THE DAY. SNACKS AND DRINKS ARE AVAILABLE FOR PURCHASE WITH CASH OR ACCOUNT CREDIT. NO REFRIGERATION OR MICROWAVE IS AVAILABLE FOR STUDENT USE.
STUDENT CELL PHONE USE IS PROHIBITED IN THE DOJO. IF YOU NEED TO REACH YOUR CHILD, PLEASE CALL THE DOJO PHONE.
ALPHA MARTIAL ARTS ACADEMY DOES NOT ASSUME ANY RESPONSIBILITY FOR THE LOSS, DAMAGE, OR THEFT OF ANY PROPERTY BELONGING TO THE STUDENT.
PLEASE LIST ANY MEDICAL CONCERNS/ALLERGIES HERE: PLEASE NOTE IF MEDICATION IS REQUIRED TO BE TAKEN AT THE DOJO, WE WILL NEED YOU TO FILL OUT A MEDICATION RELEASE FORM AND GIVE US THE PRESCRIBED MEDICATION.
PLEASE LIST ANY INFORMATION THAT YOU, AS A PARENT, THINK WE SHOULD KNOW HERE.
ILLNESS/CONTAGION INFORMATION
PLEASE LET US KNOW IF YOUR STUDENT IS ALLOWED TO FOREGO DOING MARTIAL ARTS CLASS DUE TO ILLNESS OR INJURY BEFORE CLASS, OTHERWISE THE STUDENT WILL TAKE CLASS AT THE INSTRUCTOR’S DISCRETION.
FOR THE SAFETY OF ALL OTHER STUDENTS AND STAFF, PLEASE REFRAIN FROM SENDING IN STUDENTS WITH FEVER, VOMITING, DIARRHEA & LICE.
BEHAVIOR/CORRECTIVE MEASURES INFORMATION
WHEN A STUDENT’S BEHAVIOR BECOMES INAPPROPRIATE, A WARNING WILL BE ISSUED AND CORRECTIVE MEASURES WILL BE TAKEN. ALPHA MARTIAL ARTS RESERVES THE RIGHT TO TERMINATE ANY STUDENT PARTICIPATION IN OUR AFTERSCHOOL PROGRAM AFTER THREE CONSECUTIVE WARNINGS OR AT ANY TIME.
PLEASE INITIAL THE FOLLOWING STATEMENTS IN AGREEMENT:
I ACKNOWLEGE THAT THE CAMP PROGRAM AT ALPHA MARTIAL ARTS IS A PRIVATE PROVIDER AND THAT MY CHILD’S IMAGE OR PICTURE MAY APPEAR IN ADVERTISING AND OR SOCIAL MEDIA AS PART OF PUBLICATION FOR ALPHA MARTIAL ARTS.
(Required)
Agree
I UNDERSTAND THAT ALPHA MARTIAL ARTS IS A MARTIAL ARTS SCHOOL AND NOT A DAYCARE IN AS SUCH, THEIR STOCK IN TRADE IS NOT SUPERVISION AND CARE. THEIR INTENT IS TO TEACH MARTIAL ARTS ; PHYSICAL AND DROP -IN FACILITY AND THAT AS SUCH, MY CHILD(REN) IS/ARE FREE TO COME AND GO AND IF MY CHILD(REN) IS/ARE TO STAY AT THE FACILITY, IT IS BECAUSE OF MY DIRECTION.
(Required)
Agree
I AGREE THAT I AM AWARE THAT MY CHILD(REN) IS/ARE ENGAGING IN PHYSICAL EXERCISE AND THE USE OF THE EQUIPMENT, FACILITIES, TRAINING, AND INSTRUCTION, WHICH CAN BE DANGEROUS TO THE STUDENT AND COULD CAUSE INJURY TO THE STUDENT. STUDENT IS VOLUNTARILY PARTICIPATING IN THESE ACTIVITIES AND BUYER AND STUDENT ASSUME ALL RISKS OF INJURY TO STUDENT, WHICH MAY RESULT. BUYER AND STUDENT HAVE CAREFULLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND IT IS A RELEASE OF ALL LIABILITY AND DAMAGE TO ALPHA MARTIAL ARTS FOR ANY INJURY. ALPHA MARTIAL ARTS WILL MAKE NO EVALUATION OR RECOMMENDATION WHETHER STUDENTS OR GUESTS ARE SUFFICIENTLY PHYSICALLY FIT FOR ANY EXERCISE ACTIVITIES.
(Required)
Agree
I UNDERSTAND AND AGREE TO THE INFORMATION CONTAINED IN THIS DOCUMENT. I AGREE TO COMPLY WITH THE DETAILS, RULES, AND REGULATIONS HEREIN AND I UNDERSTAND THAT DISREGARDING SAID RULES, REGULATIONS, AND DETAILS MAY RESULT IN TEMPORARY OR PERMANENT SUSPENSION OF THE PROGRAM.
EMAIL:
DATE:
MM slash DD slash YYYY
PARENT SIGNATURE:
PAYMENT INFORMATION
NEW YEARS CAMP FEE IS
$ 120.00 Per student
NO CREDITS OR REFUNDS CAN BE ISSUED ON SERVICES, EQUIPMENT, UNIFORMS, OR UNUSED DAYS.
New Years Camp - $120 PER STUDENT FOR ALL 2 DAYS
(Required)
Price:
(5% discount for 2nd student in same family, 10% discount for 3rd student in same family)
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Cardholder Name
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