First Coast Taekwondo AFTER SCHOOL PROGRAM
Kickin' Kids After School Program Registration 2018-2019
  • STUDENT'S INFORMATION

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  • Please select your child's school for the 2018-2019 school year. If the his/her school is not listed, select other and put their school name in the comment field.
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  • Bank Name/Type of CC
    Routing # (Bank Draft Only)
    Bank Account # or Credit Card #
    Expiration Date (Credit Card Only)
    If you would like to enjoy the convenience of automatic recurring billing, simply complete the Bank Draft or Credit Card Information section below and sign the form. All requested information is required. Upon approval, we will automatically bill your bank account or credit card for the amount indicated and your total charges will appear on your monthly statement. You may cancel this automatic billing authorization by sending written notice in such time (no less than two weeks prior to your next scheduled payment date) and in such manner to allow both First Coast Taekwondo and the receiving financial institution a reasonable opportunity to act on it.

    Please note this form is SSL secure. In addition, the Auto Bank Draft & Auto Credit Card Payment Information field is an encrypted field.
  • PARENT INFORMATION

    Note: If one of the fields does not apply, put N/A. Thank you.
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  • AUTHORIZED PICK-UP (other than parent/guardian)

  • 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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  • AUTHORIZATIONS

  • I agree to all the above conditions and terms of service.
  • I agree to all the above conditions and terms of service.
  • I agree to all the above conditions and terms of service.
  • AGREEMENT TO PAY

  • I agree to all the above conditions and terms of service.
  • Parent or Guardian SSN
    Parent or Guardian DL#
    DL State Issued
  • General Policies

  • I agree that I have received the above items and that the information on this enrollment form is complete and accurate.
  • I agree to all the above conditions and terms of service.
  • I agree to all the above conditions and terms of service.
  • I agree to all the above conditions and terms of service.
  • I agree to all the above conditions and terms of service.
  • I agree to all the above conditions and terms of service.
  • I agree to all the above conditions and terms of service.
  • 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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  • I agree to all the above conditions and terms of service.