Student Enrollment Application After School Program

Start Student Enrollment Application After School Program SCHOOL NEEDED FOR PICKUP: Beulah Elementary Beulah Academy of Science Pine Meadow Elementary Ransom Middle Lipscomb Elementary Brown Barge Middle (at Pine Meadow) McArthur Elementary Parent Drop Off Student Name: Belt Size: of Birth: Sex: M / F Add l Student: Belt Size: of Birth: Sex: M / F Add l Student: Belt Size: of Birth: Sex: M / F Address City State Zip Primary Parent/Guardian Relationship Home Address Primary Phone Email Cell Phone Place of Work Work Phone Secondary Parent/Guardian Relationship Home Address Primary Phone Email Cell Phone Place of Work Work Phone Emergency Contact (if parents/guardians cannot be reached) Name Relationship Phone Name Relationship Phone Authorization for Medical Attention In the event that I cannot be reached to make arrangements for emergency medical attention, I authorize the facility director or person in charge to take my child to the following if possible, or a physician of their choice. Name of Licensed Physician Phone Address Name of Hospital or Clinic Phone Address I give my consent for necessary emergency treatment when my child is in the care of this physician and/or hospital/clinic. Signature - Parent or Legal Guardian Please complete reverse side

List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries during the past 12 months, any medication prescribed for long term continuous use, and any other information. I hereby authorize the PTSDA Karate Team to allow my child to leave PTSDA Karate only with the following persons: Name Phone Name Phone Name Phone My child has permission to be release to the care of his/her siblings under 18 years old. Name of Siblings My child's immunization record, vision and hearing screening records are on file at the public school they are currently enrolled at and all immunizations are current. I acknowledge receipt of the operational policies (Parent Handbook) including those for discipline and guidance. Transportation I hereby give do not give my consent for my child to be transported and supervised by PTSDA Karate s staff. I give permission for my child to be picked up from school by PTSDA Karate. I realize that the staff and directors will do everything in their power to protect my child during these trips; however, I will not hold them responsible and waive all claims against PTSDA Karate (Chris Dufour) for any accidents that may occur during these times. Photo Release I hereby give do not give permission to PTSDA Karate Children s Program to create, release and/or reproduce my child s picture, artwork, creative writing for PTSDA Karate Children s Program website, Facebook page, Instagram and Twitter feeds without any remuneration from or repercussion to PTSDA Karate Children s Program. Signature - Parent or Legal Guardian

Afterschool Karate Guidelines Below are some Guidelines for After School Karate Program. Following these guidelines will help things run smoother for you & your child. Please read over the Parent Handbook for a more detailed list of our Operational Procedures. Student(s) attending: Hours & Fees Afterschool hours are from when school is dismissed until 6:00pm. All students must be picked up by 6:00pm. It is important that all Afterschool students be picked up on time. At 6:15pm, an additional $5 is due. Each additional 15 minutes to follow will be assessed a $10 fee. Late fees will automatically be charged to the credit card on file. Students need to be signed out every evening. Sign-out sheets are located next to Mrs. Dufour s office. Tuition is set up for automatic payment with a Debit or Credit Card. If the card is declined, a $10 fee will be added. Discounts are not given for partial weeks. Day Camp and extra activities are not included in tuition. A registration form will be available leading up to those dates. Food PTSDA Karate will provide small snacks during the day. Please try to limit foods containing peanut butter, peanuts, or peanut oil due to students with allergies and sensitivities. Students can bring snacks or purchase something from us. Cold drinks and snacks are $0.25 - $0.50. There is also a coke machine with sodas, water and Powerade for sale ranging in price from $1.25-$1.50. If you would like to prepay for snacks, we will keep a cash account for your child along with any instructions on what they are allowed to purchase daily. On Tuesday afternoons, Kona Ice makes a weekly stop. Prices for their drinks are $3 - $5. A reusable cup can be purchased and reused. Karate Karate Uniforms are to be brought each Monday, and taken home each Thursday to be washed. Students are expected to participate in their scheduled karate class. If they are unable to do so, their parent needs to contact us. Uniform available for purchase through Proshop. Student Articles Students are responsible for keeping up with their belongings. We have a Lost & Found for items that are left. All items left in Lost &Found are donated to Goodwill at the beginning of the month. Cell phones, MP3 or handheld games are to be used on Fridays only. No devices are allowed that can access the internet (wifi password will not be provided to campers). Communication with the Parents Please keep us updated with your phone numbers. If your child is sick, we must be able to reach you. You may also text us at 850-607-4454 or use the Brightwheel app to communicate. We like to send reminders to the parents via Email. Please provide us with the best email address to reach you. Email: Parent Signature

Sparring Rules and Regulations 1) Required sparring equipment* (Tiny Tigers optional): Headgear Mouthpiece Hand and feet gear Male- groin cup 2) Maintain a positive attitude while sparring. 3) Be thoughtful of your safety as well as the safety of your opponent and others. 4) Maintain a safe zone between all wall and wall décor. 5) Legal techniques include all front or reverse fist attacks to body and all front or rear leg techniques except knee kicks. 6) Illegal techniques include knee strikes, elbow strikes and head butts OR any attacks or blows which are not specific under legal target area. 7) The legal target area is defined as the front and sides of the body above the belt. Well-controlled hand or kicking techniques is permitted to areas not defined above. ***Green, Red and Black Belts are allowed light contact to the sides of the headgear and are allowed the use of open hand attack or defense techniques. 8) Illegal target areas are defined as facial, below belt, neck and back area. 9) Absolutely NO sweeping, takedowns or grappling allowed. 10) NO excessive contact. I HAVE READ AND UNDERSTOOD THE SPARRING REGULATIONS AS THEY HAVE BEEN PRESENTED TO ME. Student/Member *Sparring Gear Set available for purchase through front office. Includes all required gear plus mouthpiece case and mesh bag. Available in the following colors: Black Red Pink Teal White Blue Purple

Registration Paid Billing Agreement Student Name(s) Name on Card Billing Address & Zip Home Phone Cell Auto Payment Credit Card Card Type: Visa MC Cannot accept Discover or AMEX Card Number Exp. Amount to be charged $ Weekly Monthly Billing Agreement This agreement is between PTSDA Karate and Customer. I (We) hereby authorize PTSDA Karate to initiate weekly/monthly debit entries from the account above. This authorization for automatic debit shall remain in full force and effect until school year is complete or cancellation is submitted in accordance with the cancellation terms provided below and on the back of this Billing Agreement. I (We) hereby acknowledge that I (We) have read, understood and have agreed to all the terms of this Billing Agreement, including the additional terms on the back of this Billing Agreement and that I (We) have received a signed copy of this Billing Agreement. PTSDA Karate will appear on your bank/credit card statement. If for any reason the Draft is not approved, PTSDA Karate will add $10.00 fee. PTSDA Karate is not responsible for any bank fees incurred by Customer. PTSDA Karate has the right to resubmit returned/declined items without prior notice. If your child is not picked up by 6:00pm, late fees will automatically be charged to the credit card on file. Member s (Customer s) Right to Cancel If you wish to cancel this agreement, you must submit a request, in writing, to PTSDA Karate at least 7 days prior to the next billing date. Written request must be presented to staff and signed off by one of them. Deposits are not refundable. Without a written notice, payments will be drafted. I have read this agreement and understand that once it is signed by me it is a legally binding and enforceable obligation and I agree to comply with all the provisions, terms and conditions set forth on both sides of this agreement. I acknowledge I have received a copy of this agreement. I agree to pay the Balance Billed set forth in this agreement. Print Name Customer s Signature Prices and Terms for 2016-2017 School Year Term: 38 Weeks, (Aug. 10, 2016 May 24, 2017) Elementary Weekly Rate: One Student - $70 Two Students - $130 Three Students - $190 Elementary Monthly Rate: One Student - $280 Two Students - $520 Three Students - $760 EXCLUSION- Month of December will be half price due to Winter Break. No charge for the following weeks (optional day camps will be provided during these breaks): Nov 21, 2016 Fall Break Dec 19, 2016 Christmas Holidays Dec 26, 2016 Christmas Holidays March 20, 2016 Spring Break There are NO DISCOUNTS for days or weeks missed. Day Camp Middle School Weekly Rate: One Student - $40 Two Students - $70 Three Students - $100 Middle School Monthly Rate: One Student - $160 Two Students - $210 Three Students - $300 EXCLUSION- Month of December will be half price due to Winter Break. Day Camps are held during Teacher Planning Days, Veterans Day, MLK Day, Fall, Winter, and Spring Break. A school calendar is provided in your registration packet to aid in planning for those days.

Acceptance of Member By signing this agreement, Customer agrees to fully and completely comply with all the terms and conditions hereof and PTSDA s rules and regulations. Failure to comply with PTSDA s rules and regulations is grounds for immediate suspension or termination of the Customer and Student. PTSDA Karate and those acting under its authority reserve the right to use photographs, videotapes, artwork or other likenesses of the Customer and/or Student for marketing, trade, publishing or any other lawful purpose. Customer and/or Student understand and agree that full payment of tuition is not a guarantee or promise of advancement. Classes Scheduling and content of classes and programs, furnishing of facilities and provision of instructors to teach and supervise classes and practice sessions are at the sole and absolute discretion of PTSDA Karate and may be changed at any time by PTSDA Karate. The Customer understands and agrees that examination/testing fees may not be included in the price of this agreement. Liability Waiver and Release The Customer understands and agrees that strict observation of PTSDA s rules and regulations and the rules and regulations relative to martial arts training, including the use of protective equipment. The Customer understands and agrees that the use of PTSDA s facilities and the Member s presence at PTSDA s facility are at the sole risk of the Customer. The Customer understands and agrees that martial arts involves skills and training which includes violent and sudden movements and that in connection with the training and instruction, there will be physical contact between instructors and students, and between and among the students that such contact may result in personal injury to the student, despite precautions taken to avoid such injuries. The Customer hereby consents for the student to engage in such contact as may be necessary or required by student s participation in the training program and/or classes. The Customer, Student, and anyone claiming by or through the Customer or Student, hereby holds harmless, releases and forever discharges PTSDA Karate, its officers, directors, and representatives and the business and its instructors, agents, employees, volunteers, operators, and authorized representatives from any liability, claim, loss, including loss of property, damage, personal injury, or expense incurred by the Customer or Student and arising from the Customer s execution of this agreement, payment processing, participation in any program offered by PTSDA Karate, including, but not limited to any injury or damage caused by the negligence of PTSDA Karate, the Business, its instructors, Members, agents, employees, operators, or authorized representatives. The Customer specifically understands and agrees that he/she is assuming the risk of any and all injuries that he/she or the Students may suffer or incur as a result of his/her execution of this agreement and participation in any program offered by PTSDA Karate. TERMS AND CONDITIONS Compliance with Laws This agreement shall be governed by the laws of the State in which the Business is located. All rights and obligations of the Business and Customer under this agreement are subject to all applicable federal, state and local laws and regulations. To the extent that the terms and conditions of this agreement conflict with any applicable statute, rule or regulation in effect at the time of execution of this agreement governing transactions of the type contained herein, the agreement shall be deemed revised to conform with such statues, rules and regulations. The Business and Customer shall be bound by the modified agreement and agree that no other modifications shall be enforceable unless in writing and signed by the parties. This agreement constitutes the entire agreement between the parties and supersedes all prior agreements between the parties, whether written or oral. The invalidity or unenforceability of any provisions hereof shall not affect the validity or enforceability of any other provision. The waiver of any breach shall not constitute a waiver of any subsequent breach of this agreement. Cancellation This agreement may be cancelled by the Customer for any reason without penalty or further obligations within 3 days from the date hereof. Cancellation shall be made in writing and delivered to PTSDA Karate and signed off by a staff member. The Business may retain expenses actually incurred and the portion of the total price representing the services used and completed. Down payments and deposits are non-refundable. After the first 3 days, the Customer must give written notice, delivered to PTSDA and signed off by a staff member, no less than 7 days prior to the next scheduled payment. If notice is given in less than 7 days, the next payment draft will be made, and cancellation will take effect for the next scheduled payment. Failure to attend class or program does not constitute or imply notification to or cancellation of this agreement. Customer retains membership rights and privileges until the billing period has expired. Default Non-payment, or declined payment of scheduled payments in excess of 14 days shall constitute default under this agreement. If this agreement is in default, the entire amount owed hereunder shall become immediately due and payable, litigation may be initiated to collect all amounts due or the account referred to collection. In the event of default in payment or breach of this agreement, PTSDA Karate shall be entitled to recover their reasonable attorney fees, court costs, and interest on any past due amount at the rate of 1.15% per month. Signatories Any person(s) signing this agreement, whether as a Customer, cosigner or otherwise shall be jointly, severally and individually liable to PTSDA Karate for the full Billing price as if such person signed as the collection, including but not limited to collection agency fees, court costs, attorney s fees, and late charges that may be incurred in the event of a default.