Enrollment Date
Start Date
Source
1Parent Information
Parent #1
First Name*
Last Name*
Relationship to Child*
Email Address*
Cell Phone*
Work Phone
Address
Parent #2
First Name
Last Name
Relationship to Child
Email Address
Cell Phone
Work Phone
Address
2Student Information
Student #1
Full Name*
DOB*
Allergies
Special Needs/Concerns:
Student #2
Full Name
DOB
Allergies
Special Needs/Concerns:
Student #3
Full Name
DOB
Allergies
Special Needs/Concerns:
Student #4
Full Name
DOB
Allergies
Special Needs/Concerns:
3Emergency Contacts
4Please list everyone who may be picking up your child on the lines below.
1. A returned check will have a service fee of $25.00. For the second returned check, a $30.00 service charge will be assessed. Additionally, the above credit card/debit card will be debited for the returned check(s) plus any outstanding fees. Payment must be made in full at time of registration in order to secure your camp spot. Your prompt payment is greatly appreciated.
2. NO REFUNDS. If a pre-paid camp or event is cancelled or postponed by the organizer, a credit will be issued for an upcoming or replacement camp or event. Refunds will not be granted for missed attendance, voluntary withdrawal, or in the event of camper dismissal.
3. I understand that the intent of Loyalist Martial Arts Academy and Belleville’s Best Camps is to teach team-building, martial arts, physical and philosophical character building skills. I understand that Loyalist Martial Arts Academy is not a daycare facility, and is not equipped to provide one on one support, or accommodate specialized programming on an individual basis.
4. WAIVER & RELEASE: Buyer and Camper(s)agree that Camper(s) is engaging in physical exercise, the use of equipment, and the use of Loyalist Martial Arts Academy training and instruction facility, which can be dangerous to the Camper(s) and could cause injury or illness to Camper(s).Camper(s) is/are voluntarily participating in these activities and Buyer and Camper(s) assume all risks of injury or illness to Camper. Buyer and Camper hereby waive and release any claim or right to sue Loyalist Martial Arts Academy, employees or agents for injury or illness to Camper(s). Buyer and/or Camper have carefully read this waiver and release and fully understand, it is a release of all liabilities and damages to Loyalist Martial Arts Academy because of any injury or illness that may occur. Loyalist Martial Arts Academy will make no evaluation or recommendation whether Camper (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 martial arts activities.
5. LOSS/DAMAGE/THEFT OF STUDENT’SPROPERTY: Loyalist Martial Arts Academy does not assume any responsibility for the loss, damage or theft of any property belonging to The Camper, and Camper agrees that the school and its personnel are not responsible for or liable for any such property even if its loss, damage, or theft occurs on or about the facility.
5Parent Responsibility Checklist
6Child Responsibility Checklist
7Signature
Signature Here Please
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.