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2021 Summer Camp Online Application - ABBC Member
If you are not currently a member of Agape BBC, please click the link below
Non-Member Registration
COVID-19 Screening
We need your assistance in helping prevent the spread of the coronavirus. The safety of children in our care and our employees drives all decision-making. During these unprecedented times, we have made many hard decisions to ensure we can serve you and your child(ren) this summer. Please take a moment to review the list of questions below.
Do any of the following statements apply to you/your child(ren)?
My child has had contact with any person with known COVID-19 or person under investigation for COVID-19.
My child has shown symptoms of respiratory infection (e.g. couch, sore throat, fever, shortness of breath).
I/someone in my home is in active quarantine status.
If any of the above statements apply to you/your child(ren), we cannot accept your registration at this time. Thank you for your understanding.
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No
Camper Information
Campers Name
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Birthday
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Age
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Belt Rank
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White Belt
Yellow Belt
Orange Belt
Green Belt
Blue Belt
Brown Belt
Red Belt
Sr. Red Belt
Black Belt
Allergies
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Parent/Guardian Information
Parent/ Guardian's Name
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Relation
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Cell Phone
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Work Phone (Optional)
Address
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Street Address
Apt, Suite, Bldg. (optional)
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d\'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palestinian Territory
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
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Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
Country
Email
Emergency Contact Information
Emergency Contact Person's Name
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Relation
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Emergency Contact phone
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Insurance Company Name
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Family Physician Name
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Doctor's Phone
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CHILD IN CARE MEDICAL STATEMENT
Note: NYSED requires physical exam for new entrants and students in Grade Pre-K or K,1,3,5,7,9,& 11: annually.
Camp Information
Which Camp?
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Select the one or more
Camp #1 - July 05-09
Camp #2 - July 12-16
Camp #3 - July 19-23
Camp #4 - July 26-30
Camp #5 - August 02-06
Camp #6 - August 09-13
Camp #7 - August 16-20
Camp #8 - August 23-27
We don't know yet
Full Camp Fee (7:30AM -6:00PM)
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0
1 Full Camp $275
2 Full Camps $550
3 Full Camps $825
4 Full Camps $999 ($100 SAVING)
5 Full Camps $1274
6 Full Camps $1549
7 Full Camps $1824
8 Full Camps $1999 ($200 SAVING)
Camp Fee (8AM-3PM)
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0
1 Camp $199
2 Camps $398
3 Camps $597
4 Camps Bundle $696 ($100 Saving)
5 Camps Bundle $895
6 Camps Bundle $1094
7 Camps Bundle $1293
8 Camps Bundle $1392($200 Saving)
Camper T-Shirt Size
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ABBC Mmeber ($19.95 + tax) Non Member - Included in Registartion Fee ($49)
I already have a camp t-shirt
Youth S - $21.55
Youth M - $21.55
Youth L -$21.55
Youth XL -$21.55
Waiver
I hereby voluntarily submit my application for my attendance and participation to Agape Black Belt Center, LLC and hereby assume all responsibilities for any and all damages, injuries or losses I may sustain or incur while attending and participating. I hereby release and waive all claims against the sponsors, promoters, organizers, operators, host, instructors, associations, schools, owners, officers, directors, employees and other participants connected with Agape Black Belt Center, LLC individually or otherwise. I fully understand that in case of injury the only medical treatment provided will be first aid. I understand that I must strictly obey instructors and observe safety rules. I further agree that any photography and video taping of me in connection with Agape Black Belt Center, LLC can be used for publication, promotion, articles, and advertisements without additional consent and without compensation at this time or any other time. I understand that all registration fees are non-refundable.
Yes. I agree to tearms
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Yes
Parent/ Guardian Name
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Verification
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Example: 12
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