Camp Registration - Agape Black Belt Center

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Camper Information

Instructions **Special Promotion for 2024 Weekly Camp. Free Registration & Camp T-Shirt! ($75 Saving) **Weekly Field Trip Admission and Friday Pizza Party Are Included in the Camp Fee.

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 moreSpring Break Camp April 01-05,2024Day Camp 8:00am-3:00pmFull Day Camp 7:30am-6:00pm

Which Day(s) Type in the day(s) of camp you need.

Camp Fee *Field Trip Admission and Friday Pizza Party are included in Camp Fee.

Camper T-Shirt Size Let us sknow your child' Shirt Size. It's Included in Camp Fee!

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 terms *

Yes

Parent/ Guardian Name *

Verification

Please enter any two digits *Example: 12
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