Please fill out the form below to complete your 2019 Summer Camp Registration! Parent / Legal Guardian Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Name of Camper * First Name Last Name Camper Birthdate * MM DD YYYY Campers T-shirt size Sign me up for extended care. Sign me up for Extended Care - I want my child to have the option to arrive at 7:30am and stay until 7pm each day ($25 fee/week): * Yes No Sign me up for Enhanced Training - I want my child to participate in intensive classes in self-defense, jiu-jitsu, kickboxing and gymnastics ($25 fee/week * Yes No Name of Camper First Name Last Name Camper Birthdate MM DD YYYY Camper T-shirt size Sign me up for extended care. Sign me up for Extended Care - I want my child to have the option to arrive at 7:30am and stay until 7pm each day ($25 fee/week): * Please choose Yes No Sign me up for Enhanced Training - I want my child to participate in intensive classes in self-defense, jiu-jitsu, kickboxing and gymnastics ($25 fee/week Please choose Yes No Name of Camper First Name Last Name Camper Birthdate MM DD YYYY Camper T-shirt size Sign me up for extended care. Sign me up for Extended Care - I want my child to have the option to arrive at 7:30am and stay until 7pm each day ($25 fee/week): Please choose Yes No Sign me up for Enhanced Training - I want my child to participate in intensive classes in self-defense, jiu-jitsu, kickboxing and gymnastics ($25 fee/week Please choose Yes No Participation: I give permission for my child to participate in all activities, including field trips and to be transported as authorized by RLMA, LLC (Raise Leaders Martial Arts). This form is valid for Camp, January 1st 2019-January 1st 2020: * I grant permission Medical Treatment: I hereby give permission for my child to be given CPR and first aid treatment by a qualified staff member of the RLMA, LLC (Raise Leaders Martial Arts) staff. In the event I cannot be contacted, I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I further consent to the disclosure of health information and to the medical, surgical and hospital care treatment and procedures to be performed for my child by a licensed physician or hospital selected by the RLMA, LLC (Raise Leaders Martial Arts) director when deemed immediately necessary or advisable by the physician to safeguard my child’s health. * I grant permission Property Loss: I understand that RLMA, LLC (Raise Leaders Martial Arts) is not responsible for personal property lost, damaged or stolen while participating in our camp program and activities. * I understand Insurance: I understand it is my responsibility to provide for my child’s accident and health coverage while participating in these programs and I further understand that RLMA, LLC does not provide this coverage. * I understand Release from Liability and Indemnification: Recognizing that RLMA, LLC (Raise Leaders Martial Arts) will do its best to ensure a safe experience, I understand that accidents may occur from my child’s participation in program activities. I agree to assume these risks. By signing below, I release RLMA, LLC (Raise Leaders Martial Arts), its owners, officers, employees, volunteers, independent contractors, directors and agents from all liability based on any damage, loss, injury or death whether it is the result of ordinary negligence or otherwise, caused to my child or to me from participation in RLMA, LLC (Raise Leaders Martial Arts) programs. I further agree to indemnify and hold RLMA, LLC (Raise Leaders Martial Arts) harmless from all claims that are in any way connected with my child’s participation in this program. * I understand and accept Payment: I agree to pay my camp fees before the first day of camp attending based on the terms of this agreement. I understand that it is my responsibility to bring any billing discrepancies to RLMA, LLC (Raise Leaders Martial Arts) attention within 60 days after they first appear on my financial statements. After 60 days, I waive my right to dispute such discrepancies. * I agree Photography, Videography and Social Media: Permission is given to RLMA, LLC to use photographs and videos of myself/child (regarding martial arts and RLMA, LLC programs and activities) in promotional material. * I grant permission I do not grand permission Please define health conditions that we should be aware of: * Pick up Authorization: * Please list names and phone numbers of persons authorized to pick up your child(ren). Thank you!
