EmailMe Form - FCT AFTER SCHOOL PROGRAM

STUDENT'S INFORMATION

Child's Full Legal Name *

Preferred Name

Child's Gender *

Male

Female

Child's Date of Birth *

MM / DD / YYYY

Elementary School Name *

Please select your child's school for the 2017-2018 school year. If the his/her school is not listed, select other and put their school name in the comment field.

Child's Grade 2017-2018 School Year *

START DATE IN OUR AFTER SCHOOL PROGRAM
(Clay County starts Tuesday, 8/15/17 and Duval County starts Monday, 8/14/17) *

MM / DD / YYYY

Days Attending After School Program *

Has child had any of the following: (if yes, please explain below in the Special Needs of Child field) *

Surgery

Serious Illness/Accident

Allergies

None of the Above

Any Special Needs of Child and/or Medication the Child is Currently Taking?

Child's Physician Health Resource Name *

Child's Physician Health Resource Phone # and Address *

Additional information - If there is anything else you would like to inform us about, please note below:

Payment Option (Select one):

Auto Payment $79 a week (2nd child $75)

Pay in Person - $84 a week (2nd Child $76)

Save money by setting up automatic payment. Auto payments save us time and money on billing. Auto bank draft or auto credit card payments may be set-up weekly, bi-weekly or monthly. Setting up auto payment saves us money and allows us to pass the savings on to you. (Auto payment information and authorization form will be completed in person at our location.)

PARENT INFORMATION

Note: If one of the fields does not apply, put N/A. Thank you.

Who Has Legal Custody of the Child & Relationship to Child? *

Parent 1 Name

First Last

Parent 1 Relationship to Child (e.g. Mom, Dad, Grandmother, ect) *

Parent 1 Address

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

Parent 1 Cell Phone Number *

### - ### - ####

Parent 1 Home Phone Number

### - ### - ####

Parent 1 Work Phone Number

### - ### - ####

Parent 1 Email Address *

Parent 2 Name

First Last

Parent 2 Relationship to Child (e.g. Mom, Dad, Grandmother, ect) *

Parent 2 Address

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

Parent 2 Cell Phone Number

### - ### - ####

Parent 2 Home Phone Number

### - ### - ####

Parent 2 Work Phone Number

### - ### - ####

Parent 2 Email Address

AUTHORIZATIONS

PERMISSION TO RIDE: I (We) hereby grant permission for said child to ride to the after school program located at 7540 103rd Street Landing Suite #109, Jacksonville, FL 32210 and/ or to any field trips. *

I agree

I agree to all the above conditions and terms of service.

MEDICAL TREATMENT: 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. I have noted any special health-related conditions of allergies regarding my child. *

I agree

I agree to all the above conditions and terms of service.

AUTHORIZATION TO PARTICIPATE IN MARTIAL ART CLASSES & RELEASE FORM
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.

This document affects you and/or your child's legal rights. You must read and understand this agreement before signing it. *

I agree

I agree to all the above conditions and terms of service.

AGREEMENT TO PAY

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)

ABSENCES & VACATIONS: In an effort to keep prices as low as possible and ensure a quality program, the After School Program is updating the absences policy effective 8/14/17.

There are no deductions in weekly tuition fees for absences and vacations. However, your child will receive two free vacation weeks once he or she has been attending our after school program for six months (full time).

Withdrawal:
A two week notice is required when withdrawing from our After School Program. However, if a proper notice is not provided, a reduced fee of one-half of your child's weekly tuition fee for each week of notice not provided will be charged. *

I agree

I agree to all the above conditions and terms of service.

KNOW YOUR CHILDCARE FACILTY & INFLUENZA BROCHURE & DISCIPLINARY PRACTICES

In addition, Section 402.3125(5), F.S., requires that parents receive a copy of the Child Care Facility Brochure, "Know Your Child Care Facility” (CF/PI 175-24), and the current "Influenza Virus Brochure". These items can be viewed on the department of children and families website at http://www.myflfamilies.com/service-programs/child-care/brochures-facts-progress or you may request at the front desk or via e-mail.

Section 65C-22.006(3)(c)2., F.A.C., requires that parents are notified in writing of the disciplinary practices used by the child care facility. See behavior policy in the next field or you may request a copy at the front desk or via email.

Your signature below indicates that you have received the above items and that the information on this enrollment form is complete and accurate. *

I agree

I agree that I have received the above items and that the information on this enrollment form is complete and accurate.

BEHAVIOR POLICY

At First Coast Taekwondo, our goal is to promote behavior that is conductive to learning. We always take into consideration the age and individual needs of the child. We focus on the child’s behavior, not the child’s personality. We strive to communicate to the children that they are always accepted and cherished.

It is important to distinguish between what are acceptable or supportable and what are unacceptable or insupportable behaviors.

We promote good behavior by using positive reinforcement such as:
• Treasure box
• Stickers
• Good Note home
• Piece of candy
• 1st Choice on Activities
• Extended time on favorite activity
• Surprise Treats

However, if a child is not acting appropriately, the following measures are taken:
• The first offense will result in a warning.
• Second offense will result in being removed from friends and/or activity for a short period of time. The child will be sent to a table for a quite activity (reading, coloring, or playing with puzzles).
• Third offense will result in writing sentences. When a child has to write sentences, he/she will not be allowed on the video games or their most preferred activity for the remainder of the day. In addition, parents will be notified if this action was taken. *

I agree

I agree to all the above conditions and terms of service.

General Policies

I am aware and agree to the following general policies of the KK After School Program:

*First Coast Taekondo’s drop off and pick up times & policy
*Tuition Policy, Absences and Vacation Policy
*Policies of Parent Handbook, including the behavior policy
*Two week withdrawal notice
*Authorization to Participate in Martial Art Classes and Release Form
*Food and Nutrition Policy
*Holiday’s that First Coast Taekwondo is closed
*Homework Policy
*Toy Policy
*Movie Policy *

I Agree

I agree to all the above conditions and terms of service.

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

No, I do not authorize my child to be photographed

I agree to all the above conditions and terms of service.

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 Time *

MM / DD / YYYY