After School (ASK) Summer / Fall Break / Spring Break / Day Camp)

Please fill out all forms found on the 7 tabs below.

PICTURES AND VIDEO PERMISSION FORM

From time to time, Northside Karate School shoots video or takes photos of the children in their normal daily activities in karate and the After-School Karate Program. These photos may be used on our website or in the advertising of these programs. We ask that our parents release the use of such images by signing this form below.

I give Northside Karate School permission to take pictures/video of my child, while engaged in normal daily activities at Northside Karate School’s and activities sponsored by them. I understand these images may be used in ads for the program, in art projects the kids are doing in the program, or for “bulletin boards” or other decoration within the school.

Parent/Guardian Signature:

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PICTURES AND VIDEO PERMISSION FORM

Parent/Guardian Signature:

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Month

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DISCIPLINE (BEHAVIOR) POLICY FORM

TO ALL PARENTS/GUARDIANS, KARATE CAMPERS AND AFTER SCHOOLERS: Review the contents of this Discipline (Behavior) Policy and acknowledge your agreement of the terms by signing in the space provided. The form must be returned with your registration packet.

In an effort to give your child and all students a safe and fun experience, it is necessary that all students exhibit proper behavior, self-discipline and self-control. Correcting unsatisfactory behavior is time consuming and detracts from providing a safe environment full of fun and educational activities.

If the NSK staff is unable to control a situation, we will contact the parent/guardian(s) first by telephone at or near the area of disturbance. It is requested that parents/guardians reinforce (by phone) the requirements that all students enrolled in any NSK program, will behave satisfactorily and follow instructions fully and promptly.

After appropriate warnings to the parents/guardians, students who cannot be controlled by verbal commands or who present a constant disciplinary problem will be suspended without a refund of any type.

DISCIPLINE POLICY: When the NSK staff experiences repeated inappropriate behavior from any enrolled student, that child will be given ample verbal warnings of their improper actions and instructions how to correct the negative occurrences. After being removed (set out) from the group's activity, if the student’s negative behavior continues, NSK staff will contact parents/guardians for prompt assistance (by phone) in changing the child’s negative actions. Upon the second disciplinary action requiring a phone call to a parent/guardian, NSK staff will REQUIRE parents/guardians to immediately make arrangements (one hour or less) to pick-up their child for the rest of the day.

First name

Last name

I, Fill in name above (Parent/Guardian’s printed name) herby acknowledge and have discussed this policy between myself and NSK staff. I understand it and agree to abide by all of its terms and conditions.

Parent/Guardian Signature:

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AUTHORIZATION TO DISPENSE MEDICATION

NSK shall not handout prescription or nonprescription medications to any child without specific written authorization from the child’s physician and/or parent/guardian. All medications shall be stored in accordance with the prescription instructions and kept in places that are inaccessible to children. Each dose of medication given to a child shall be documented showing the child’s name, name of medication, amount administered, date and time, and the name of the NSK staff member dispensing that medication. Parent/guardians will be contacted before any medication is dispensed to their child.

Child's Name

Date of Birth

Month

Day

Year

Permission is hereby granted to dispense medication(s) to the above mentioned minor child at the appropriate time.

Parent/Guardian Signature

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MEDICAL INFORMATION FORM

Child's Name

Date of Birth

Month

Day

Year

Parent or Legal Guardian:

Address

Emergency Numbers

Mom Cell

Mom Work

Dad Cell

Dad Work

Additional Contact

Additional Contact Name

Additional Contact #

Additional Contact 2 Name

Additional Contact 2 #

CONSENT & RELEASE

Initials

I hereby give my consent to Northside Karate School(NSK), its instructors, and employees or any emergency medical personnel to administer the necessary treatment to my child (named above). In addition, in the event of an emergency, I give my consent to have my child transported by ambulance, if the situation warrants.

Initials

I hereby give my consent to Northside Karate School(NSK), its authorized agents to transport any child (named above) to and from Northside Karate School(NSK) or other Northside Karate School’s authorized activities.

I understand, that while in Karate Camp and/or After School Karate, we will be engaging in the following activities: SWIMMING, PAINTING, MOONWALKS, GO KARTING, AMUSEMENT PARK RIDES, GOING TO THE PARK, MONKEY BARS, ROLLER SKATING, ICE SKATING, BASKETBALL, KARATE, NATURE WALKS and MANY MORE ACTIVITIES AND SPORTS. Being aware of the risks and hazards inherent to the use of certain equipment or the facilities in After School Karate activities, I hereby assume all risk of loss, damage and injury, including death that may be sustained by my child.

In signing this Consent and Release Form, I hereby acknowledge and represent that I have read the foregoing, understand its terms, and sign it voluntarily. I ALSO ACKNOWLEDGE THAT MY CHILD IS IN EXCELLENT PHYSICAL HEALTH AND IS ABLE TO ENDURE STRENUOUS RECREATIONAL ACTIVITIES AND PLAY, INCLUDING THE ABOVE- NAMED ACTIVITIES AND OTHERS NOT MENTIONED OR STATED.

Parent/Guardian Signature

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AGREEMENT, ASSUMPTION OF RISKS, AND WAIVER OF LIABILITY

I hereby certify that I have read and agreed to each of the following provisions and agree to be bound by the terms herein:

I understand that Northside Karate, and such other martial arts as instructors and I include in my studies at Northside Karate, are martial arts -- that is, systems of unarmed and armed fighting techniques.
I understand that these martial arts will require me to engage in strenuous physical exercise and activity, either individually or in participation in class with other students or instructors at Northside Karate, and that the martial arts techniques which I learn at Northside Karate are capable of causing minor or serious physical injury (including abrasions, bruises, bleeding, broken bones or cartilage, or other tissue or organ damage), emotional or psychological injury, death, or property damage, whenever I use them against another person or physical objects, either in class at Northside Karate or elsewhere.
I understand that my participation in class at Northside Karate will require me to engage in conditioning exercises, formal exercises, and other physical activities that involve a risk that I will be subject to minor or serious physical injury (including abrasions, bruises, bleeding, broken bones or cartilage, or other tissue or organ damage), emotional or psychological injury, or death as a result of these exercises and activities.
I understand that the types of injuries described in paragraphs 2 and 3 may result not only from intentional action, but also from inadvertent, negligent, or reckless action, by myself or others, including the malfunction or failure of any of the equipment or facilities at Northside Karate (including pads, protectors, punching bags, and tumbling mats) and errors or mistakes in instruction or performance of fighting or defense techniques by instructors or other students at Northside Karate.
I understand that the risks of any and all of the types of injuries described in paragraphs 2-4 cannot be significantly reduced or eliminated without adversely affecting, and even jeopardizing, the nature and quality of the instruction and activities at Northside Karate.
I understand that neither Northside Karate nor any of its owners, operators, officers, employees, instructors, students, or agents authorize me to use any of the fighting or defense techniques that I learn in my studies at Northside Karate against any other person, in any circumstances other than (a) martial arts training, matches, exhibitions, or demonstrations in which my instructors and I agree I am sufficiently qualified and physically able to participate at Northside Karate or elsewhere, and (b) self-defense or defense of others in a situation that involves the risk of imminent physical injury or death.
In the light of all of the foregoing understandings, I knowingly and voluntarily agree to assume all of the risks associated with participation in classes at Northside Karate or any of its outside locations , including those risks described in paragraphs 2-4, and knowingly and voluntarily hold harmless, and waive any and all rights to initiate or maintain a lawsuit or otherwise seek or obtain any finding of liability against, Northside Karate and any of their owners, operators, officers, employees, instructors, students, or agents.
I intend this Agreement, Assumption of Risks, and Waiver to be binding upon any and all of my parents, children, present and former spouses or life partners, heirs, assigns, friends, personal representatives, and estate in perpetuity.

CONSENT FOR EMERGENCY TREATMENT

I hereby give permission for my child/children to receive emergency treatment (first aid and CPR) by a qualified staff member of Northside Karate School.

I also give permission for my child/children to be transported by ambulance, aid car, or staff car to an emergency center for treatment. In the event that I cannot be contacted, I further consent to the medical, surgical, and hospital care treatment and procedures to be performed for my child by a licensed physician to safeguard my child’s health.

In case of emergency, and if emergency transportation is needed, I agree to pay all costs of transportation.

Child’s Physician

Physician’s Address

Preferred Hospital

Hospital Address

Clinic Phone Number

Hospital Phone Number

Medical Insurance

Insurance Numbers

Date of Last Tetanus (or DPT)

Month

Day

Year

Allergies:

Mother’s Name

Father’s Name

Parent/Guardian Signature

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Month

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Year

Best Value

Summer Registration

$85

Every week

+$60 Registration fee one time payment

June 2 to August 11 (10 weeks )

Valid for 10 weeks

Step 1. Click the blue Select button to purchase

Step 2. Fill out the registration form below.

Step 3. Make sure to fill out and submit each form

KARATE CAMP PROGRAM APPLICATION

Child’s Name

Age

Birth Date

Month

Day

Year

Grade

Camp Programs(Summer / Fall Break / Spring Break / Day Camp)

PURPOSE

The Camp Program strives to provide a safe, healthy, positive learning environment, with character developing education through martial arts training, while enjoying an individual supportive atmosphere. The summer program is designed to assist elementary school students with their physical, education and psychological growth, while having tons of fun.

POLICIES HOURS OF OPERATION

The Camp Program is in session Monday through Friday 6:00 am to 6:00pm. NSK Camps are not in session during the following Federal holidays, Memorial Day, 4th of July, Labor Day, Christmas, and New Year’s Day. All campers should be picked up no later than 6:00pm. As of 6:35pm, a late fee will be charge at a one dollar ($1.00) per minute rate. Payments of late fees are due by Thursday of the camper's current week. Campers’ WILL NOT leave the NSK Camp area until he or she is SIGNED OUT by the designated parent/guardian listed within this "Camp Program Application." In case of an emergency, Camp teachers can be reached at (832) 969-5584/ (832) 878-1185; please leave a message if no one physically answers at this number. The answering machine connected to this number is checked regularly.

HEALTH AND SAFETY

If a child exhibits signs of illness, the responsible parent/guardian will be notified, and the camper will be excluded from all activities. In the event that a camper becomes physically ill and needs to be picked up, they will be separated from the rest of the campers until a parent/guardian arrives. A local emergency name and telephone number must be on file for each child, in case the parent/guardian cannot be contacted. Information concerning allergies or health restrictions must also be on file, along with a physician’s name and telephone number. The Karate Program does not offer Accident Insurance on the children; therefore, a signed release statement must be on file for each child verifying that the parent will assume FULL responsibility for any and all expenses incurred due to injury in the program. Children must wear shoes and the appropriate clothing to all sponsored Karate Programs.

SNACKS & LUNCH

Lunch and three (3) Snacks are provided by the parent/guardian daily, PLEASE NO GLASS BOTTLES!!! Lunches and snacks must not require heating or refrigeration. To prevent unintentional food poisoning, lunch boxes with reusable ice packs should be used when providing your child with diary or meat items. It is recommended that parents/guardians separate lunch items from the intended snack treats, this keeps your child from eating all their food in one meal.

PERSONAL BELONGINGS

Personal game stations and toys are only permitted on specified days and must be approved by the director. NSK staff will not take responsibility for any broken, lost or stolen items. NSK staff will make every attempt to help locate missing items; however, we cannot take responsibility for replacing them. It is advised that parents/guardians check their camper's personal property daily for any unauthorized items. Ensure all your camper's personal belongings are clearly labeled. Cell phones are not allowed during Camp hours, if a child needs to contact their parent/guardian, they will be allowed to use an NSK staff phone. Camp teachers can be reached at (832) 969-5584/ (832) 878-1185; please leave a message if no one physically answers at this number.

DISCIPLINE

Discipline shall be consistent and fair. Limits and rules are designed to be understood by the camper for whom they apply. No corporal punishment will be administered at any NSK Camps. When a child exhibits disruptive behavior, it will be documented, and the parent/guardian will be notified. Upon the second infraction, if the circumstances warrant, the parent/guardian may be called to pick-up the child. A conference will be arranged between the NSK staff and the parent/guardian. Additional offenses may result in suspension or dismissal from the Camp program. A child that has been dismissed will not be eligible for re-enrollment in the program. IF AT ANY TIME A CHILD’S BEHAVIOR ENDANGERS THE SAFETY OF THEMSELVES OR OTHERS, THE CHILD MAY BE DISMISSED FROM THE PROGRAM IMMEDIATELY. (See Discipline Statement for further description).

ACKNOWLEDGEMENT OF POLICIES

I acknowledge that I have read and received this NSK camp program purpose and policies summary.

PARENT/GUARDIAN SIGNATURE

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Date

Month

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Year

CHILD 1 NAME

CHILD 1 AGE

CHILD 1 GRADE

CHILD 2 NAME

CHILD 2 AGE

CHILD 2 GRADE

CHILD 3 NAME

CHILD 3 AGE

CHILD 3 GRADE

Address

MOTHER’S NAME

MOTHER'S PHONE HOME

MOTHER'S PHONE WORK

MOTHER'S PLACE OF EMPLOYMENT

MOTHER'S EMAIL ADDRESS

FATHER’S NAME

FATHER'S PHONE HOME

FATHER'S PHONE WORK

FATHER'S PLACE OF EMPLOYMENT

FATHER'S EMAIL ADDRESS

Please list ALL MEDICAL INFORMATION (Allergies, Nosebleeds, Headaches, etc.) or other information required for the safe care of your child / children.

In the event of an emergency requiring immediate attention, the NSK staff has authorization to secure the necessary medical treatment.

Physician’s Name

PHYSICIAN'S NUMBER

I HAVE READ AND UNDERSTAND ALL OF THE POLICIES GOVERNING THE KARATE CAMP PROGRAM AND WILL ABIDE BY THEM.

Parent / Guardian Signature

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Date

Month

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Year

After School (ASK) Summer / Fall Break / Spring Break / Day Camp)

Please fill out all forms found on the 7 tabs below.

PICTURES AND VIDEO PERMISSION FORM

PICTURES AND VIDEO PERMISSION FORM

DISCIPLINE (BEHAVIOR) POLICY FORM

AUTHORIZATION TO DISPENSE MEDICATION

MEDICAL INFORMATION FORM

Emergency Numbers

CONSENT & RELEASE

AGREEMENT, ASSUMPTION OF RISKS, AND WAIVER OF LIABILITY

CONSENT FOR EMERGENCY TREATMENT

RELEASE AUTHORIZATION

Person(s) to call when, in an emergency, the parent(s) cannot be reached:

Summer Registration

KARATE CAMP PROGRAM APPLICATION

Camp Programs(Summer / Fall Break / Spring Break / Day Camp)

ACKNOWLEDGEMENT OF POLICIES

Three Locations!