Kimery Martial Arts

    Activity Center For Kids That Want To Move

    AFTER SCHOOL * SUMMER CAMP * SPRING BREAK

* THANKSGIVING CAMP * CHRISTMAS CAMP 

  Circle the above that you are registering for

        COPY OF DRIVER LICENSE? YES NO (Please give license to person taking application for a copy)

FIRSTNAME_____________________________LAST________________________________________

ADDRESS___________________________________CITY________________ZIP_________________

BIRTHDAY ____ /____/_____ AGE______ TEACHERS NAME __________________

HOME PHONE__________________ WORK ______________________ CELL ____________________

  School Your Child Will Attend: NORTHSIDE         PEARL LOWER         PEARL UPPER        OTHER

REGISTRATION $45.00 NOT/ PAID WEEKLY AMOUNT _________ CASH / CHECK #_______

PARENTAL INFORMATION

                        Mother                                                                                 Father

Home Address

Name ______________________________________ Name ______________________________________

Address ____________________________________ Address ____________________________________

Telephone (H)____________________________ Telephone (H)____________________________

(W)____________________________ (W)____________________________

(C)____________________________ (C)____________________________

    Business Address

Company Name ____________________________ Company Name ______________________________

Address ____________________________________ Address ____________________________________

Telephone (H)____________________________ Telephone (H)____________________________

(W)____________________________             (W)____________________________

(C)____________________________              (C)____________________________

    EMERGENCY CONTACTS

Please list at least 2 relatives or friends who may be contacted in the event of an emergency. We will contact these individuals when the parent of guardian cannot be reached.

Name ________________________    Relationship to Child _____________________

Home Telephone ___________________ Work #_____________________________

Cell ___________________

Name ________________________ Relationship to Child ______________________

Home Telephone ___________________ Work Telephone ______________________

Cell ___________________

      Authorized Pick-Up List

    If in the event I am not available 

_________________________                   ________________________


_________________________________                   ________________________________


______________________________                   _________________________________



PLEASE READ AND CIRCLE YES OR NO

  I have received a copy of the Parent Handbook and a copy of the Mississippi State Department of Health Regulation Summary for Parents. I have read both of these and understand the contents of each.

YES NO Initial _______

Photography Authorization- I give my permission for the child listed on this application to be photographed or videotaped while in attendance at this center during center activities.

YES NO Initial _______

I give my permission for the child listed on this application to participate in field trips sponsored by this center. I understand that I will need to sign a permission slip for each field trip.

YES NO Initial _______

I authorize this center to administer prescription and non-prescription medication as necessary for my child. I understand that medication of all types will only be administered per published instructions, obtained either from the physician or from the original container of the medication

YES NO Initial _______

I authorize this center to obtain any and all medical treatment to be performed as deemed necessary by licensed medical personnel, including emergency medical personnel, ambulance personnel and hospital doctors and nurses.

YES NO Initial _______

*Special instructions concerning your child if medical treatment is prohibited due to religious reasons

  Signature Parent / Guardian Required ____________________________________ Date____________________

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