First Coast Taekwondo - Kickin' Kids Registration
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GENERAL INFORMATION
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| Child's Full Legal Name
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| Preferred Name
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| Child's Gender
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Female Male
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| Child's Date of Birth
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| Mother's Name
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| Prefix
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| First
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| Last
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| Suffix
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| Mother's Address
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If unknown, put "unknown"
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| Street Address
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If unknown, put "unknown"
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| Address Line 2
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If unknown, put "unknown"
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| City
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If unknown, put "unknown"
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| State / Province / Region
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If unknown, put "unknown"
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| Postal / Zip Code
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If unknown, put "unknown"
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| Country
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If unknown, put "unknown"
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| Mother's Cell Phone Number
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| Mother's Home Phone Number
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| Mother's Work Phone Number
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| Mother's Email Address
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| Mother's Employer
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| Mother's Work Address
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If unknown, put "unknown"
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| Street Address
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If unknown, put "unknown"
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| Address Line 2
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If unknown, put "unknown"
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| City
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If unknown, put "unknown"
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| State / Province / Region
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If unknown, put "unknown"
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| Postal / Zip Code
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If unknown, put "unknown"
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| Country
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If unknown, put "unknown"
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| Father's Name
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| Prefix
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| First
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| Last
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| Suffix
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| Father's Address
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If unknown, put "unknown"
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| Street Address
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If unknown, put "unknown"
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| Address Line 2
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If unknown, put "unknown"
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| City
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If unknown, put "unknown"
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| State / Province / Region
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If unknown, put "unknown"
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| Postal / Zip Code
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If unknown, put "unknown"
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| Country
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If unknown, put "unknown"
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| Father's Home Phone Number
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| Father's Cell Phone Number
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| Father's Work Phone Number
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| Father's Email Address
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| Father's Employer
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| Father's Work Address
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If unknown, put "unknown"
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| Street Address
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If unknown, put "unknown"
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| Address Line 2
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If unknown, put "unknown"
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| City
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If unknown, put "unknown"
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| State / Province / Region
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If unknown, put "unknown"
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| Postal / Zip Code
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If unknown, put "unknown"
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| Country
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If unknown, put "unknown"
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AUTHORIZED PICK-UP
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Authorized Pick-Up (other than parent/guardian)
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:
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| 1. First and Last Name of individual authorized to pick-up
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| Address
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| Phone Number
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| 2. First and Last Name of individual authorized to pick-up
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| Address
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| Phone Number
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MEDICAL INFORMATION
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| Any Special Needs of Child?
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| Has child had any of the following:
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| If any of the above are checked please explain below.
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| I give permission to consult a physician in case of emergency if I/we cannot be reached.
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| Electronic Signature of Custodial Parent or Legal Guardian
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This signature must be that of the individual "signing" this document electronically, otherwise it constitutes forgery under s.831.06, Florida Statutes
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AUTHORIZATION TO TAKE INTO CUSTODY
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A representative of First Coast Taekwondo, will be taking your child into custody for the purpose of escorting him/ her to First Coast Taekwondo and/ or field trips.
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| Elementary School Name
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| Child's Grade
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| Teacher's Name
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POLICIES & REGULATIONS
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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 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.
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| Electronic Signature of Custodial Parent or Legal Guardian
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This signature must be that of the individual "signing" this document electronically, otherwise it constitutes forgery under s.831.06, Florida Statutes
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Permission to Ride Form
I (We) hereby grant permission for said child to ride to the after school program located at 8970 103rd Street Landing Suite #4, Jacksonville, FL 32210 and/ or to any field trips on the following days:
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| Days attending
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| Students will be traveling in the following manner:
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1. I authorize school representatives to obtain medical treatment for my child in case of serious illness or injury and agree to pay for such treatment.
2. I have noted any special health-related conditions of allergies regarding my child.
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| Electronic Signature of Custodial Parent or Legal Guardian (if participant is under 18)
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This signature must be that of the individual "signing" this document electronically, otherwise it constitutes forgery under s.831.06, Florida Statutes
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| Date
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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)
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| I agree to all of the above conditions and terms of service.
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I agree
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| Date
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| Parent or Guardian SSN:
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| Parent or Guardian DL#:
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| State Issued:
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| Expiration:
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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 8970 103rd Street Landing Ste #4, 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.
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| Please state any medical condition(s) the student has that First Coast Taekwondo and the Releasees should be made aware of:
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If no allergies or medical condition, please put "none" or N/A".
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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
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| Date of Birth
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| If under 18, Name of guardian
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| Electronic Signature of Participant:
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This signature must be that of the individual "signing" this document electronically, otherwise it constitutes forgery under s.831.06, Florida Statutes
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| Electronic Signature of Custodial Parent or Legal Guardian (if participant is under 18)
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This signature must be that of the individual "signing" this document electronically, otherwise it constitutes forgery under s.831.06, Florida Statutes
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| Date
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Absences and Payment
Payment: Since expenses continue whether or not you child is present, there are no deductions in weekly tuition fees for absences. Please notify the center if your child is ill and will not be attending. However, if you child is ill for a full week, a reduced fee will be due totaling one-half of the weekly tuition fee.
Contact us: Parents must notify the center if their child did not go to their academic school or was picked up early by 12pm. If you cannot speak with someone personally, please leave a message on the answering machine. This is extremely important, because it is difficult to obtain this information from the schools and this delay may cause us to be late picking up children from the other schools.
Vacations: If a child is absent for a full week for vacation or extended illness, a reduced rate of one-half the weekly tuition will be charged. After two week, regular tuition will be charged. Your child will receive two free vacation weeks once he or she has been attending our after school program for six months (full time).
Holidays: Our center is closed for all national holidays: New Year's Day, Memorial Day, Good Friday, 4th of July, Labor Day, Thanksgiving Day and Christmas Day. Tuition remains the same. Our center may also be closed on occasion for the day prior or day following a Holiday or Taekwondo School Event. These closings will be posted in advance.
School Closing: We may open during Christmas and Spring Break and other school closings if there is a high demand from the parents. For weeks were schools are closed one day, there is a $10 - $20 additional tuition fee for the full day if your child attend
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| I agree to all of the above conditions and terms of service.
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I agree
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Tuition and Pick-Up Policy
Tuition:
Tuition is due on Monday or the first day of a child's scheduled attendance for the week. Parents who receive any type of subsidized care are responsible for their portion of the weekly fee. Checks are to made to First Coast Taekwondo. Tuition is late on Wednesday morning and a $10 delinquency fee will be charged per day until your account is current.
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.
Last, at approximately 6:40pm, the Kickin' Kids' room will be closed. Children remaining after 6:40pm will be brought to the viewing room with their belongings. For children in class after 6:30pm, their belongings will also be brought to the viewing room. We will not be able to allow children back into the Kickin' Kids' room after 6:40pm because there is no supervision. Again, your cooperation is greatly appreciated.
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| I agree to all of the above conditions and terms of service.
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I agree
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Snacks, Dinner, and Lunch
Snacks:
Our after school program includes a 15 to 20 minute snack break in its schedule. We provide a snack and drink for each child. This snack is included in the weekly tuition fee. If you desire, you may send an additional snack with your child.
Dinner:
If your child takes a late class, you may send a meal with him/ her that day to eat around 5:15pm. You may not send microwavable foods. We cannot store food for future use/consumption. Last, please do not send money for your child to purchase food from restaurants. We do not have he ability to pick-up the meals and cannot let your child go pick-up these items on his/her own.
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).
If you child forgets a lunch, FCT will provide him/her a lunch from Nika's Pizza (a choice of selected items is provided) and a $6 fee will be charged.
Note: Lunch and dinner are available to purchase daily from Nika's Pizza.
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| I agree to all of the above conditions and terms of service.
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I agree
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Other Information and Movie Agreement Sheet
Other Information:
Sign In and Out
You must sign your child out every evening when you pick him/her up. Also, if you drop your child off, you must sign your child in. This is very important because of regulations.
Toy Policy
Your child my bring his/her game boy or other games to Kickn' Kids Extended Day. All we ask is that 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.
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| I agree to all of the above conditions and terms of service.
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I agree
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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.
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| I give consent to have my child's photograph taken.
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| I agree to all of the above conditions and terms of service.
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I agree
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START DATE
Clay County schools start Tuesday, 8/14/12. Duval County schools start Monday, 8/20/12.
Please put your childs expected start date:
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| Electronic Signature of Custodial Parent or Legal Guardian (if participant is under 18)
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This signature must be that of the individual "signing" this document electronically, otherwise it constitutes forgery under s.831.06, Florida Statutes
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| Date
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Emergency Contact
Please fill out the following emergency contact information in the case of an emergancy and a parent can not be reached. If your child's emergency contact information changes, please provide the updated information.
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| Emergency Contact #1
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| Prefix
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| First
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| Last
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| Suffix
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| Home Phone Number
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| Cell Phone Number
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| Work Phone Number
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| Emergency Contact #2
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| Prefix
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| First
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| Last
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| Suffix
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| Home Phone Number
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| Cell Phone Number
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Image Verification
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EMF Form Creator