Tampa Bay Karate…Kick for Success!

  APPLICATION

Please circle program:  AFTER SCHOOL     SUMMER CAMP    OUTREACH       EVEING CLASS

Registration Form

Call for details 813-270-5592 

Child’s Name _______________________________________________

                                         (One form per child please.  Form may be copied)

Address ________________________________ City ____________________

State Zip________ Daytime phone ___________________________

Cell phone ________________Parent or Guardian Name ______________________

Emergency Contact _______________________________________

Phone _______________Relationship to  Child________________________

Name of school : _________________________________

Teacher Name and Grade: __________________________________

Please list any allergies or medical conditions of child:

I, __________________________________________________, understand that Tampa Bay Tang Soo Do Karate  provides An after school  program and spring break program.  I agree to accept full risk and responsibility for my child’s participation in the karate  program(s)  and I agree to release, hold harmless and indemnity Tampa Bay Tang Soo Do Karate, Ed Morgan Associations, and all employees, agents or representatives of Tampa Bay Tang Soo Do karate in their official and individual capacities, from all expenses, attorney fees, claims or liability whatsoever, including claims based upon such defendants; own negligence arising from or related to my child’s participation in Tampa Bay Tang Soo Do Karate summer camp program.  This release shall be binding on me, my legal representatives, heirs and assigns in perpetuity.  I have read this release and understand it fully.

_____________________________________________________________              _______________________________

Parent or Guardian Signature                                                                                                                            Date