2021 Summer Camp Online Application - Non-Member

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. *

No

Camper Information

Instructions First Time Campers Need to Pay $49 One Time Registration Fee. It Includes 1 Camper's T-Shirt ($21.55 Value). If Your Child(ren) is a Returning Camper, Register at ABBC Member's Registration Page.

Campers Name *

Birthday *

Age *

Allergies *

Parent/Guardian Information

Parent/ Guardian's Name *

Relation *

Cell Phone *

Work Phone (Optional)

Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Email

Emergency Contact Information

Emergency Contact Person's Name *

Relation *

Emergency Contact phone *

Insurance Company Name *

Family Physician Name *

Doctor's Phone *

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? *

Select the one or moreCamp #1 - July 05-09Camp #2 - July 12-16Camp #3 - July 19-23Camp #4 - July 26-30Camp #5 - August 02-06Camp #6 - August 09-13Camp #7 - August 16-20Camp #8 - August 23-27We don't know yet

Full Camp Fee (7:30AM -6:00PM) *

Camp Fee (8AM-3PM) *

Registaration Fee

First Time Campers Need to Pay $49 One Time Registration Fee. It Includes 1 Camper's T-Shirt ($21.55 Value). If Your Child(ren) is a Returning Camper, Register at ABBC Member's Registration Page.One Time Camp Registration Fee $49

Camper T-Shirt Size *ABBC Mmeber ($19.95 + tax) Non Member - Included in Registartion Fee ($49)

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 *

Yes

Parent/ Guardian Name *