After School Program Registration – Jon Paul Roberts Family Taekwondo

After School
Program Registration

Enrollment Date *

Start Date *

Referred By

Email Address

Parent Last Name *

First Name *

Student 1 *

Date of Birth *

Name of School *

Student 2

Date of Birth

Name of School

Student 3

Date of Birth

Name of School

Student 4

Date of Birth

Name of School

Address *

City *

State *

Zip *

Home Phone *

Work Phone

Cell Phone

Employer

Job Title

Employer Address

City

State

Zip

D.L. # *

State Issued *

Spouse/Other Parent

Cell Phone

Employer

Job Title

Employer Address

Work Phone

City

State

Zip

Emergency Contact *

Relationship *

Phone *

Martial Arts School *

Yes, I understand.
I understand that Jon Paul Roberts TaeKwonDo Summer Program is a martial arts school and not a daycare in as such; Jon Paul Roberts Summer Program stock-in-trade is not supervision and care. The intent of Jon Paul Roberts Summer Program is to teach martial arts physical and philosophical character building skills. I understand that Jon Paul Roberts Summer Program is a martial arts school and is a drop-in facility in as such; my child(ren) is free to come and go. Additionally, if my child(ren) stay at Jon Paul Roberts Summer Program facility it is because of my direction and not Jon Paul Roberts Summer Program.

Payments *

Yes, I understand.
I understand that payments not received by due date will have a $5.00 late fee accessed. In addition that payment is delinquent for more than one week a $5.00 late fee will be due for the first week, plus a $10 fee for each additional week thereafter, child(ren) will not be admitted into camp until payment and all applicable fees are paid in full. A returned check will have a service charge fee of $10.00 and resulting in the right to have all future transactions made in the form of CASH ONLY.

Absenteeism *

Yes, I understand.
If your child(ren) have been absent for more than TWO weeks you will lose your place in the Summer Camp Program, unless prior arrangements have been made with Trisha or Jon Paul Roberts.

Waiver & Release *

Yes, I understand.
Buyer and Student agree that Student(s) is engaging in physical exercise, and the use of equipment, use of the Jon Paul Roberts Summer Camp Program facilities, training and instruction, which can be dangerous and could cause injury to Student(s). Student(s) is voluntarily participating in these activities and Buyer and Student assume all risks of injury to Student. Buyer and Student hereby waive and release any claim or right to sue Jon Paul Roberts Summer School Program, employees and agents for injury to Student(s). Buyer and/or Student(s) have carefully read this waiver and release and fully understand, it is a release of all liability and damage to Jon Paul Roberts Summer Program for any injury. Jon Paul Roberts Summer Camp Program will make no evaluation or recommendation whether Student(s) or guests are physically fit for any exercise activities. it is always advisable to consult your physician before undertaking a physical exercise program, particularly karate activities.

Loss/Damage/Theft of Student Property *

Yes, I understand.
Jon Paul Roberts Summer Camp Program does not assume any responsibility for the loss, damage, or theft of any property belonging to the Student(s) and Student(s) agrees that Jon Paul Roberts Summer Camp Program and its personnel are not responsible for, or liable for any such property even if loss, damage, or theft occurs on or about Jon Paul Roberts Summer Program facility.

Authorized Pick Up Person Name

Date of Birth

Phone

Authorized Pick Up Person Name

Date of Birth

Phone

Authorized Pick Up Person Name

Date of Birth

Phone

After School
Program Registration

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