First Coast Taekwondo - Summer Camp Registration
|
GENERAL INFORMATION
|
| Child's Full Legal Name
*
|
|
|
| Preferred Name
*
|
|
|
| Child's Gender
*
|
Female Male
|
| Child's Date of Birth
*
|
|
|
| Elementary School Name
*
|
|
|
MEDICAL INFORMATION
|
| Any Special Needs of Child?
|
|
|
| Has child had any of the following:
*
|
Surgery Serious Illness/Accident Allergies None of the above
|
| If any of the above are checked please explain below.
|
|
|
Child's Swim Ability (select one):
If your child is a weak or non-swimmer, please provide your child with a
SWIM VEST on Pool Days.
*
|
Non-Swimmer Weak Swimmer Moderate Swimmer Strong Swimmer
|
SUMMER CAMP: WEEKS ATTENDING
Please list your child's start date and end date for our Summer Camp program below. Also, for each Summer Camp week posted below, please mark whether your child will or will not be attending the applicable week. As a reminder, if your child is absent for an entire week, you must provide two weeks notice in writing (which includes this form). If two weeks notice is not provided, you will only be charged half tuition for that week.
• Summer Camp starts Monday, June 5th and ends Monday, August 14th
• Drop of Window: 7am to 9am, Students must arrive by 9am as our field trip departure starts at 9am
• Pick-up by 6:30pm
|
| Summer Camp Start Date (Duval County's Last day of school is 6/2 & Clay County's Last Day of school is 6/7)
*
|
|
|
| Summer Camp End Date (Duval County's 1st Day of School is 8/14 & Clay County's 1st Day of School is 8/15)
*
|
|
|
| Days attending
*
|
Monday Tuesday Wednesday Thursday Friday
|
| Summer Camp available weeks (select each week your child is attending)
*
|
June 5th - June 9th, 2017 (Clay County's Last Day of School is 6/7) June 12th - June 16th, 2017 June 19th - June 23rd, 2017 June 26th - June 30th, 2017 July 3rd - July 7th, 2017 (closed July 4th) July 10th - July 14th, 2017 July 17th - July 21st, 2017 July 24th - July 28th, 2016 June 30th - August 4th, 2016 August 7th - August 11th, 2016 Monday, August 14th (Clay County Only- Duval County Starts school this day) As a reminder, if your child is absent for an entire week, you must provide two weeks notice in writing (which includes this form). If two weeks notice is not provided, you will only be charged half tuition for that week.
|
SUMMER CAMP WEEKLY TUITION
(Daily Field Trip & Lunch Included, 2nd Child discount is $9)
|
$149 per week- Auto Bank Draft $154 per week - Auto Credit Card $159 per week - Pay in Person Save money by setting up automatic payment. Auto payments save us time and money on billing. Also, the transaction fees on bank drafts are much cheaper than credit cards fees. Setting up auto payment saves us money and allows us to pass the savings on to you.
|
Auto Bank Draft & Auto Credit Card Payment Information
(Not required if selected "Pay in Person" option)
For Auto Bank Draft Payment, provide 1) Bank Name, 2) Routing Number and 3) Bank Account #
For Auto Credit Card Payment, provide 1) Type of CC (ex. Visa), 2) Name on Card, 3) Card Number and 4) Expiration Date
|
|
|
| Mother's Name
*
|
|
|
| Prefix
|
|
|
| First
*
|
|
|
| Last
*
|
|
|
| Suffix
|
|
|
| Mother's Address
*
|
If unknown, put "unknown"
|
| Street Address
*
|
If unknown, put "unknown"
|
| Address Line 2
|
If unknown, put "unknown"
|
| City
*
|
If unknown, put "unknown"
|
| State / Province / Region
*
|
If unknown, put "unknown"
|
| Postal / Zip Code
*
|
If unknown, put "unknown"
|
| Country
*
|
If unknown, put "unknown"
|
| Mother's Home Phone Number
|
|
|
| Mother's Work Phone Number
|
|
|
| Mother's Cell Phone Number
*
|
|
|
| Current Email Address
*
|
|
|
| Mother's Employer
|
|
|
| Father's Name
|
|
|
| Prefix
|
|
|
| First
|
|
|
| Last
|
|
|
| Suffix
|
|
|
| Father's Address
|
If unknown, put "unknown"
|
| Street Address
|
If unknown, put "unknown"
|
| Address Line 2
|
If unknown, put "unknown"
|
| City
|
If unknown, put "unknown"
|
| State / Province / Region
|
If unknown, put "unknown"
|
| Postal / Zip Code
|
If unknown, put "unknown"
|
| Country
|
If unknown, put "unknown"
|
| Father's Home Phone Number
|
|
|
| Father's Cell Phone Number
|
|
|
| Father's Work Phone Number
|
|
|
| Father's Employer
|
|
|
| Current Email Address
|
|
|
AUTHORIZED PICK-UP
|
Authorized Pick-Up (in addition to parents listed above)
The child will be released only to the parent(s) authorized, or in the manner authorized in writing, by the custodial parent(s) or legal guardians(s). The following people are authorized to remove the child from the facility in case of illness, accident or emergency, if for some reason the custodial parent(s) or legal guardian(s) cannot be reached:
|
| 1. First and Last Name of individual authorized to pick-up
|
|
|
| Phone Number
|
|
|
| 2. First and Last Name of individual authorized to pick-up
|
|
|
| Phone Number
|
|
|
1. I authorize school representatives to obtain medical treatment for my child in case of serious illness or injury (based on the judgment of our staff) and agree to pay for such treatment.
2. I have noted any special health-related conditions of allergies regarding my child in the fields above.
*
|
I agree
|
POLICIES & REGULATIONS
|
Parents Acknowledgement of Rules and Regulations
I hereby acknowledge receipt of the First Coast Taekwondo Kickin Kids After School and Summer Camp Program Rules and Regulations and Policies (that can be obtained from the front desk or viewed at http://www.firstcoasttaekwondo.com/After_school_program.html.) I further attest that I have reviewed the Disipline Procedures and Policies with my child(ren) and by signing below I agree to abide by these rules and regulations.
I am aware of and agree to :
First Coast Taekwondo's drop off and pick up times.
Attendance Policy
Policies of Parent Handbook
Two week withdrawal notice
Holiday's that First Coast Taekwondo is closed.
|
Permission to Ride Form
I (We) hereby grant permission for said child to ride to the after school and summer camp program located at 7540 103rd Street Suite #109, Jacksonville, FL 32210 and/ or to any field trips.
|
| Students will be traveling in a 15 Passenger Vehicle and Company Private Passenger Vehicle:
|
15 Passenger Vehicle & Company Private Passenger Vehicle
|
Parents Agreement to Pay
I am responsible for making weekly tuition payments as set forth by First Coast Taekwondo. Payments are due on Monday of each week, and become delinquent after Tuesday's close of business. A $10.00 late fee will be assessed each time a payment is delinquent. Payments are accepted in the form of cash, check, Debit, VISA or MasterCard. Checks are to be made payable to F.C.T. (First Coast Taekwondo)
|
| I agree to all of the above policies, regulations, conditions and terms of service.
*
|
I agree
|
Agreement of Release
I the person named below being above the age 18, or the legal guardian of the person named below who is under 18, in consideration of the services of First Coast TaeKwonDo any rate charged for those services, and the right to engage in activities at the facilities provided by First Coast TaeKwonDo at 7540 103rd Street Ste #109, as a participant; hereby acknowledge, agree, promise, and covenant with First Coast TaeKwonDo and all other persons or entities which may be connected to First Coast TaeKwonDo as follows:
1. IN CONSIDERATION OF THE BENEFITS DERIVED FROM FIRST COAST TAEKWONDO, I AGREE TO INDEMNIFY, RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE FIRST COAST TAEKWONDO, OR ITS INSTRUCTORS, their agents, servants, and employees, and assigns and any and all other persons or entities which are related to, arise out of or are in any way connected with participation in TAEKWONDO instructed by First Coast TaeKwonDo. For the purposes herein, they shall be referred to as “Releasees,” from all liability to the named participant, or the legal guardian of the named participant, his or her personal representatives, assigns, heirs, and next of kin for any and all loss or damage, and any claim or demands therefore. On account of injury or illness to the person or property or resulting in the death of the named participant, whether caused by the negligence of the “Releasee,” or otherwise while the participant is participating in TaeKwonDo, as supervised by the Releasees, whether it be active participation or mere observance.
2. I and/or MY LEGAL GUARDIAN EXPRESSLY ACKNOWLEDGE, UNDERSTAND, AND APPRECIATE, AS ANY CAREFUL, CONSCIENTIOUS, EVEN TEMPERED, AND HONEST “REASONABLE PERSON” WOULD, THE FORESEEABLE RISKS WHICH MAY BE INVOLVED IN THE PARTICIPATION OF TAEKWONDO, Which by its nature includes strenuous exercises, and BODY CONTACT. I and/or MY LEGAL GUARDIAN also expressly consents to confront these foreseeable dangers, and further agrees, understands and recognizes that these risks may result in SERIOUS INJURY or illness, including bruises, bloody noses, broken bones, and/or DEATH, and/or property damage. I further understand and acknowledge that these risks may result in personal claims against the Releasees, First Coast TaeKwonDo, or claims against me by other participants and third parties, but I expressly covenant not to sue the Releasees for any damages which may result from the named participant’s participation in TaeKwonDo.
3. I and/or MY LEGAL GUARDIAN HEREBY FORESEE THE RISKS OF AND ASSUME FULL RESPONSIBILITY FOR ANY BODILY INJURY, including bruises, bloody noses, broken bones, or other serious injury resulting in death or property damage relating to the duty of care of the releasess or otherwise, while participating in TaeKwonDo supervised by the releasees. I and/or my legal guardians further expressly agree that the foregoing Release, Waiver, and Indemnity Agreement is intended to be as broad and inclusive as is permitted by the laws of the state of Florida or the law of the province or state in which an event is conducted and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
4. I and/or MY LEGAL GUARDIAN(S) HAVE READ AND VOLUNTARILY SIGNED THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements, or inducements apart from the foregoing written agreement have been made. By voluntarily affixing my signature below, I warrant that I have read the entire Agreement and understand all of the foregoing: IN SIGNING THIS DOCUMENT, I FULLY RECOGNIZE THAT IF ANYONE IS HURT OR PROPERTY IS DAMAGED WHILE I AM PARTICIPATING IN TAEKWONDO INSTRUCTED BY FIRST COAST TAEKWONDO, I WILL HAVE NO RIGHT TO MAKE CLAIM OR FILE A LAWSUIT AGAINST FIRST COAST TAEKWONDO, ITS OFFICERS, AGENTS, EMPLOYEES, OR SUPPORTERS, EVEN IF THEY OR ANY OF THEM FAILED THEIR DUTY OF CARE AND WERE NEGLIGENT ANY BODILY INJURY OR PROPERTY DAMAGE.
|
| Please state any medical condition(s) the student has that First Coast Taekwondo and the Releasees should be made aware of:
*
|
If no allergies or medical condition, please put "none" or N/A".
|
This document affects you and/or your child's legal rights. You must read and understand this agreement before signing it.
Full Name of Participant
*
|
|
|
| Date of Birth
*
|
|
|
| If under 18, Name of guardian
*
|
|
|
| Electronic Signature of Participant:
|
This signature must be that of the individual "signing" this document electronically, otherwise it constitutes forgery under s.831.06, Florida Statutes
|
| Electronic Signature of Custodial Parent or Legal Guardian (if participant is under 18)
*
|
This signature must be that of the individual "signing" this document electronically, otherwise it constitutes forgery under s.831.06, Florida Statutes
|
| Date
*
|
|
|
Tuition and Pick-Up Policy
Tuition:
Tuition is due on Monday or the first day of a child's scheduled attendance for the week. Tuition becomes deliquent after Tuesday's close of business. A $10 delinquency fee will be charged each time a payment is delinquent. If there is a problem with tuition payment, please talk with your director. Will will make every effort to accommodate special circumstances, but you may be asked not to bring your child until payment can be made.
Pick-Up Policy:
Children must be picked up by 6:30pm unless their class ends after 6:30pm. On days your child attends a class after 6:30pm, pick up time is extended until the ending time os his or her class. Last, on the days there are no Taekwondo classes, all children should be picked up by 6:30pm. Please make every effort to be on time, as there are late fees.
Late fees will be charged for children remaining after 6:30pm. The office clock is used to determine lateness. Parents who pick up their children after closing time will be charged $10 for the first 5 minutes and $1 for each additional minute per child. All monies are due and payable to the staff remaining with your child upon parent's arrival.
We realize there are emergencies and unexpected situations. If you are aware that your child will not be picked up on time, please contact us so we can plan accordingly. Your communication and cooperation are greatly appreciated.
|
| I agree to all of the above conditions and terms of service.
*
|
I agree
|
Lunch
During the summer, early release days and the days children do not have school, please provide a bagged lunch (no microwavable or refrigerated items) unless otherwise advised (i.e. field trip includes lunch).
Or lunch is available to purchase daily.
If you child forgets a lunch, FCT will provide him/her a lunch and a $6 fee will be charged.
|
| I agree to all of the above conditions and terms of service.
*
|
I agree
|
Other Information and Movie Agreement Sheet
Other Information:
Sign In and Out
You must sign your child in every morning at drop-off and out every evening when you pick him/her up.
Toy Policy
Your child my bring his/her game boy or other games. We ask you please put their name on all items and remember we are not responsible for any lost items.
Uniform and Gear
Please make sure your child has his/her uniform and gear for class. Students cannot participate in class without a uniform and may not take sparring class without gear.
Every child has a cubby for his/her uniform and gear. Occasionally, your child's gear should also be taken home for cleaning.
Last, please make sure your child's uniform, belt, and gear has his/her name on it.
Lost and Found:
We will keep lost items in the lost and found bin for two weeks.
Movie Agreement Sheet:
During the summer, we watch movies daily and occasionally during the school year. We watch G and PG movies.
I, the parent/guardian named below, give permission for my child named below to watch G and PG movies shown at First Coast Taekwondo.
|
| I agree to all of the above conditions and terms of service.
*
|
I agree
|
Photograph Release Form
I, the parent/ guardian listed below, authorize First Coast Taekwondo to photograph and video my child named below. I understand that these photographs may be used for public/FCT Website display and/ or advertising purposes.
|
| I give consent to have my child's photograph taken.
*
|
Yes, I authorize my child to be photograhed
|
| Electronic Signature of Custodial Parent or Legal Guardian (if participant is under 18)
*
|
This signature must be that of the individual "signing" this document electronically, otherwise it constitutes forgery under s.831.06, Florida Statutes
|
| Parent or Guardian DL#:
*
|
|
|
| Date
*
|
|
|
| If there is anything else you would like to inform us about, please note below:
|
|
|
|
Image Verification
|
|
|
|
|
|
EMF Survey
EMF Survey