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8650 Spicewood springs road,
Suite 103
Austin, Tx 78759

8650 Spicewood springs road,
Suite 103
Austin, Tx 78759

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Location

8650 Spicewood springs road,
Suite 103
Austin, Tx 78759

512-459-1806 Free Trial

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Fillable Registration

AUSTIN KENPO KARATE STUDENT ENROLLMENT FORM

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Student Information

Week 1-10

D.O.B

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Parent Information

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Parent/Guardian:

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Emergency Contact/Pick Up Information

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(Emergency contacts in case parents/guardians can’t be reached. I authorize these individuals to pick up my child in the event that I cannot. List individuals in the order that you

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would like for us to call in case of emergency and parent/guardians call in case of emergency and parent/guardians cannot be reached.)

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Please fill out the entire information including the Address C.F.P.S requires it.

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1.

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Name:

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Student Name:

Receipt of Summer Camp Operational Policies (Check box and Sign). This is a legally binding contractual agreement. It is strongly advised that you thoroughly read the Operational

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Policies and all contracts, and that you discuss any concerns or questions with the Director, prior to signing and submitting said paperwork.

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I have read and understand the policies set forth in the Operational Hand Book and agree to the conditions and terms outlined. No other verbal or written modification of these documents exists.

Signature of Parent/Legal Guardian

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Transportation

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(Check all the boxes and sign.)

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I give permission for my child to be transported and supervised to/from AKK.

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Liability Waiver

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I give permission for my child

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(Print Child's Name)

to attend the Summer Camp Program offered by Austin Kenpo Karate. I state that my child is physically fit to take karate and understand that the staff and instructors at Austin

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Kenpo Karate will do everything in their power to protect my child while in their care. I acknowledge that Austin Kenpo Karate will transport my child as necessary to and from

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activities that will be located away from the school, and that I will not hold Austin Kenpo Karate or its students or instructors liable for any automobile accident, nor liable for any

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injuries that may occur and assume that the risk associated with such transport and activities is comparable to the risk assumed when normally transporting my child in an

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automobile. I further acknowledge that Karate is a contact sport and like any other sport I realize that there are some personal risks, and that I am assuming that risk and hold

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harmless Austin Kenpo Karate and its instructors and students while my child is in their care.

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Signature of Parent/Legal Guardian

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Printed Name:

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Emergency Medical Information and Immunization Records

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In the event that I cannot be reached to provide emergency medical for my child I, authorize the instructor or representative of Austin Kenpo Karate to seek medical treatment for my child and/or to administer first aid and/or CPR.

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Student's Name

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Family Physician Contact Information

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Address:

Insurance Information:

I give permission for my child to be treated at a local emergency room if necessary. Preferred of Emergency Room (if possible):

I give consent to emergency medical treatment as seen fit by Austin Kenpo Karate in the event I cannot be reached or if an emergency does not permit time for Austin Kenpo Karate to reach me first.

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My child’s immunization record is on file at the public or private school they are attending and all immunization and tuberculosis tests are current. All necessary vision and hearing

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screenings as required by the Special Senses and Communications Disorders Act are current and on file at the public or private school my child is attending.

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Signature of Parent/Legal Guardian

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Printed Name:

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Medical History

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Please list any medical conditions your child has such as allergies, illnesses, and injuries in the past 12 months that merited medical treatment and any medicines prescribed for

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longterm continuous use. Write “none” if this does not apply to your child.

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AUTOMATIC CREDIT CARD BILLING AUTHORIZATION FORM (MERCHANT #64959781)

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To set up your account for automatic billing, complete the Credit Card information below. All requested information is required to set up the account. Upon approval, Austin Kenpo

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Karate will automatically bill your credit card for the registration fee, if applicable, and thereafter the full amount of tuition and fees every week, 2 weeks prior to the Monday of

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the 1st day of attendance for that week. All charges will be in accordance with the policies set forth by Austin Kenpo Karate. Your total charges will appear on your monthly credit card statement.

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Billing will end either at the date specified by this contract, or when customer provides 30-day advance written cancellation via email at: sifu@austinkenpokarate.com, and is

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accepted via email by Austin Kenpo Karate. I agree to pay, and authorize Austin Kenpo Karate to charge, the credit card listed below: any and all late, cancellation, and other

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applicable fees in accordance with policies of the contract/program agreed to at time of enrollment and/or renewal.

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Fees: In order to secure your child’s placement registration and tuition in full for first 2 weeks must be paid 2 weeks prior to start date

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Registration Fees (Check One):

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The following penalties will be assessed in the event that the student(s) does not complete their enrollment as agreed: $75.00 per week. Cancellation of attendance for any week

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must be made 30 days or more in advance, via email, and a response given by Austin Kenpo Karate. Failure to cancel within these guidelines will result in a charge for tuition and

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fees for that week, even if notification is made prior to the charge; if you cancel within these guidelines you will not be charged, except for the cancellation fee. Registration fees are non-refundable.

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Discounts (check one):

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Weeks Child Will Attend (check all that apply):

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Method of Payment (Please refer to Operational Policies for rates):

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Credit Card (choose one):

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Authorized Amount:

Enter payment amount for option checked above PLUS registration fee if applicable, You authorize Austin Kenpo Karate to automatically debit the card every week for the tuition

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rate checked above plus event fees listed in this Operational Policies and/or as agreed upon between you and Austin Kenpo Karate. No other agreement exists of this contract

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unless agreed upon, in writing via email or facsimile transmittal, between you and Austin Kenpo Karate DO NOT write contractual changes on this form; they will be considered null and void.

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Cardholder Address:

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Methods to Submit Student Application Form (ALL pages):

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1. Mail completed, signed forms and payment to Austin Kenpo Karate, 5501 N. Lamar Blvd. #A-225, Austin, TX 78751. Must be received by due date as outlined in Operational

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Policies to guarantee placement. We will attempt to reach you using the contact information given on this form to acknowledge receipt.

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2. Deliver your paperwork in person (necessary for cash payments; optional for all others). Please call us prior to coming in, as instructors are not always available to take your

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paperwork and payment from you. We will do our best to work with your schedule.

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3. Email: Send completed paperwork to sifuSchroder@gmail.com

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If you are mailing your payment and would like to receive a paper receipt prior to the first day of after school pickup, please check which method you would like to receive it (otherwise you will receive your receipt on the first day of class):

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Mail

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How did you hear about us? (Check all that apply)

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Current student

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I have read and understood the policies set forth in the operational handbook and agree to the conditions and terms outlined. No other verbal or written modification of these documents exists.

AUSTIN KENPO KARATE

5501 N Lamar Blvd ( Closed )

Suite A 225,

Austin, Texas 78751

AUSTIN KENPO KARATE

8650 Spicewood Springs Road ,

Suite 103,

Austin, Texas 78759

Phone. 512-459-1806

Email. sifuschroder@gmail.com

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