Family Karate Center 
Christian Martial Artist Coalition, Inc.
(Office)
4546 Pine Street - Office
Fruitland Park, Florida  34731 
(Camp Location)
1313 Griffin Road  -  Leesburg, FL
(across from Beverly Shores Elementary)  

 Date ____________

Student Name _____________________________________ Age ____ Sex ____ D.O.B. ___________________

Parent’s name ___________________________________________ (If student is under 18 years of age)

Address _____________________________________________ City _________________ Zip ______________

Res. Phone _______________________ Bus. Phone ____________________ Cell Phone ___________________

SS# __________________________  D.L.# ____________________________ E-mail ______________________

Spouse’s Name ________________________________ emergency contact phone _________________________

How did you hear about us? ______________________________

Academic School your child attends _______________________________ Grade ____ Teacher _____________

PLEASE NOTE: To reserve your child’s place weekly, payment is due on the Friday preceding the week of attendance. You will have a grace day, which is on Monday.

If your child is out for more than two (2) weeks you will lose your child’s place in the after school program or summer camp and you will be required to re-register

unless you pay a $40.00/week holding fee to secure your child’s place.

~Any payment received after Monday will have a late fee of $5.00/day until paid. If payment is not made by Monday, we cannot provide services until payment is made!

However, If your child’s first day is Monday – Friday payment is due on the first day of attendance.

~ There is a $30.00 service charge for any returned checks. Two returned checks will result in payment by cash only!

NOTE: NO REFUNDS! Payments are for 3-5 days/week. Also, we do NOT generate payment history so keep your receipts.

~ Pick Up time is 6:00 p.m. and a late fee of $15.00 will be assessed if your child is not picked up by 6:00 p.m.

Initial here X_____

I, _________________ UNDERSTAND THAT FAMILY KARATE CENTER IS A MARTIAL ARTS SCHOOL AND NOT A DAYCARE IN AS SUCH, THEIR STOCK IN

TRADE IS NOT SUPERVISION ANC CARE. THEIR INTENT IS TO TEACH MARTIAL ARTS PHYSICAL AND CHARACTER BUILDING SKILLS. I UNDERSTAND THAT

 FAMILY KARATE CENTER IS A MARTIAL ARTS SCHOOL AND IS A DROP-IN FACILITY AND THAT AS SUCH, MY CHILD(REN) IS/ARE FREE TO COME AND GO

AND IF MY CHILD(REN) ARE TO STAY AT THE FACILITY, IT IS BECAUSE OF MY DIRECTIOIN AND NOT THE CENTERS.

AUTHORIZATION SIGNATURE ____________________________________________ DATE_______________________

WAIVER/RELEASE

WAIVER/RELESE: You, Buyer and Student, agree that you are aware that Student is engaging in physical exercise, and the use of equipment, use of facilities, training,

and instruction, which can be dangerous to the Student and could cause injury to the Student. Student is voluntarily participating in these activities and buyer and Student

assume all risk of injury to student which may result. Buyer and Student hereby waive and release any claim  or right to bring suit against Family Karate Center,

Christian Martial Artist Coalition, Inc., Christ United Methodist Church, Instructors, Employees, Agents, and fellow Students for any injury to Student which may result.

Buyer and Student have carefully read this agreement and fully understand this is a waiver and release of all liability and damage(s) of   Family Karate Center,

Christian Martial Artist Coalition, Inc., Christ United Methodist Church, Instructors, Employees, Agents, and fellow Students for any injury and/or losses.  Family Karate Center,

the Instructor(s), employees, will make no evaluation or recommendation whether Student or guests are sufficiently, physically fit for any exercise activities. It is always best

to consult your physician before undertaking any physical exercise program particularly Martial Arts.

LOSS/DAMAGE/THEFT OF STUDENT’S PROPERTY: Family Karate Center, Christian Martial Artist Coalition, Inc., Christ United Methodist Church, Instructors, Employees,

Agents, and fellow Students does not assume any responsibility for the loss, damage, or theft of any property belonging to the Student and the Student agrees that

Family Karate Center, Christian Martial Artist Coalition, Inc., Christ United Methodist Church, Instructors, Employees, Agents, and fellow Students are not responsible

for or liable for any such property even if its loss, damage, or theft occurs on or about the facility.

VIDEO/PICTURES: I understand that pictures and video may be taken of my child(ren) and give my consent for any and all to be used for positive purposes of building dojo

enrollment through advertising and various other purposes.

Buyer’s (Parent’s) signature ________________________________________  Student’s Signature _____________________________

Instructor’s Signature _____________________________________________   Date ___________________________