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TAEKWONDO
6349 Columbia Pike, Suite C ▪ Falls Church, VA 22041 U.S.A. 703 - 914 - 1110 |
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UMS 2010 TAEKWONDO SUMMER CAMP REGISTRATION FORM
1. Student Name: Age: M / F LAST FIRST
2. Student Name: Age: M / F LAST FIRST
3. Student Name: Age: M / F LAST FIRST
Guardian’s Name: Email: LAST FIRST
Address: STREET APT# CITY STATE ZIP
Home Phone: W: C:
Emergency Phone: PHONE NAME RELATION
Any special conditions we need to keep in mind or allergies/medications we need to be aware of? We are registering for ___ weeks! (Circle all that apply)
SUMMER CAMP RATES: 1 - 5 weeks = $199/wk 6 - 8 weeks = $189/wk 9 - 10 weeks = $179/wk
Registration Fee: $60 per student (includes Taekwondo uniform & camp T-Shirt) $ # - CC Paid On: / / . (NONREFUNDABLE) Student 1. X + = $ Add Field Trip Fees that apply for each student: WEEKLY RATE # OF WEEKS FIELD TRIP FEES 2. X + = $ Bowling / Chuck E. Cheese: $20 (Includes Lunch & Tokens) 10% OFF WEEKLY RATE # OF WEEKS FIELD TRIP FEES 3. X + = $ Movie: $16 (Includes Soda & Popcorn) 10% OFF WEEKLY RATE # OF WEEKS FIELD TRIP FEES TOTAL $ - Down Payment$ # - CC Paid On: / / 2[$ # - CC Paid On: / / ] 7[$ # - CC Paid On: / / ] Initial 3[$ # - CC Paid On: / / ] 8[$ # - CC Paid On: / / ] when 4[$ # - CC Paid On: / / ] 9[$ # - CC Paid On: / / ] PAID in 5[$ # - CC Paid On: / / ] 10[$ # - CC Paid On: / / ] FULL â 6[$ # - CC Paid On: / / ] ______
Auto Credit Card#: Exp. Date: MONTH / YEAR TERMS OF AGREEMENT
Payment/Cancellation/Modification Policy: Registering for this camp allows the students listed above an open space in the camp. The registration fee is non-refundable. Payment for the number of selected weeks secures the entire week, even if the students listed above do not attend the entire week. Credits cannot be given for partial weeks. Payment in full, before the first week of enrolled Taekwondo Summer Camp, is recommended, but payment consultation with a UMS Martial Arts representative for payment options is required. Payments not received on time are charged a late penalty of $25. There is a $25 service charge for any returned checks or declined credit card payments. Two weeks written notice must be given to cancel or modify this agreement and a $10 fee is charged for cancellation or modification of this agreement. The rates applied to the selected weeks of camp before the modification or cancellation are subject to change and any back payments are to be made before the next week begins. Late pick up charges are as follows and are to be paid before the end of the camp week: $10 from 6:31-6:45 pm and $5 for every 15 minute segment thereafter. Failure to make payments may result in dismissal from the camp. Waiver and Release: I, as the child(ren)’s legal guardian, fully recognize that martial arts involves strenuous physical exercise and I am fully aware of the risks of injury and/or illness inherent in participation in any fitness or martial arts program, and I have taken all reasonable steps to determine, and hereby warrant, that my child(ren) is(are) in good health and physically capable of participating in the programs and courses of instruction offered by UMS Martial Arts. I understand and agree that all participation in any such fitness program or use of UMS Martial Art’s equipment or facilities on or off the premises, including field trips, shall be at our own risk. I authorize the officers and personnel of UMS Martial Arts to transport my child(ren) to and from UMS Martial Arts in any event, and in the case of a medical emergency I authorize UMS Martial Arts and its officers and personnel to seek medical attention for the student's) mentioned above. I also authorize the attending physician to perform any emergency treatment that is deemed necessary. I hereby release, indemnify, and hold harmless UMS Martial Arts and its personnel from and against any and all claims, suits, demands, damages, costs and liabilities of any kind or any kind of nature, including attorney’s fees and costs, for any injury, harm or fatalities of myself or my child(ren), or of any person(s) who become entitled to the use of the facilities of UMS Martial Arts by virtue of this agreement, or any third persons, which arise directly or indirectly out of or in virtue of our presence at UMS Martial Arts for any form of compensation or claim for any fatalities, harm or injuries sustained by our presence at UMS Martial Arts.Loss, Damage, and Theft of Property: I understand and agree that UMS Martial Arts and its personnel shall not be held responsible for any personal property which is damaged, lost or stolen in or around UMS Martial Arts or its facilities, or at any of UMS Martial Arts’ off-premises events and field trips.Photographic Equipment: I hereby authorize UMS Martial Arts personnel to photograph me or my child(ren) and to utilize such photographs for commercial purposes, including but not limited to the promotion and marketing of UMS Martial Arts, and I agree that I or any party acting on my or my child(ren)’s behalf shall not be entitled to receive compensation as a result of such use.
Guardian’s Signature*: Printed: Date: *By signing you have read and agree to the terms above.
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HAPKIDO