Alpha Martial Arts Academy

6849 Buffalo Road, Palmetto, FL 34221

(941) 544-5572

one Day CAMP REGISTRATION

ONE DAY CAMP REGISTRATION

DATE:

STUDENT 1 NAME:(Required)

First Last

STUDENT’S DATE OF BIRTH:

STUDENT 2 NAME:

First Last

STUDENT’S DATE OF BIRTH:

STUDENT 3 NAME:

First Last

STUDENT’S DATE OF BIRTH:

ADDRESS:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 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:

PARENT SIGNATURE:

PAYMENT INFORMATION

DAILY CAMP FEE IS (PER DAY): $ 65.00 Per student
NO CREDITS OR REFUNDS CAN BE ISSUED ON SERVICES, EQUIPMENT, UNIFORMS, OR UNUSED DAYS.

ONE DAY - $65 PER STUDENT(Required)

Price:

(5% discount for 2nd student in same family, 10% discount for 3rd student in same family)

Credit Card(Required)

Cardholder Name

Card Details