Clark's Self Defense Karate Adventure Summer Camp

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1 Clark's Self Defense Karate Adventure Summer Camp Our Summer Karate Camp is one of the most unique summer camps available to children. It provides an enriching selection of self defense activities as well as many fun summer activities. Our camp is a fun-packed week long program consisting of Karate, swimming, rock climbing, bungee jumping, field trips, indoor and outdoor sports, art & crafts, and character development. We provide a fun and exciting summer program that will safely introduce students to the Martial Arts, and also polish and expand the skills of those with previous experience. Children will participate in games that will help them with focus, balance, and self confidence. They will learn to work with others, set goals and form a supportive team. The camp will be directed by a certified fifth degree black belt Derrick Clark. Children between the ages of 5 and 12 are invited to sign up for this exciting camp. We are looking forward to working together to provide a successful, safe, and fun summer for all our campers. Fees and Policies 1. Early and Extended care Early Care and Extended Care are available to all students at additional $5 each, daily. 2. Lunch All campers must bring lunch and beverage with them each day. Snacks will be provided. 3. Gear Needed Daily Campers should bring sunscreen, water bottle, swimwear, Camp Shirt, and towel every day. Hat and sunglasses are optional. 3. Sibling discounts Families enrolling more than one child will be given a 25% discount for the second child. 4. Tuition Full week: $200/week (1-2 weeks) $165/week (3 4 weeks) $130/week (5 6 weeks) 5. Location Campers should be dropped off at our studio located at 4952 Fruitville Road in Sarasota, FL, in the Fruitville Plaza. 6. Contact Numbers Director: Derrick Clark (941) Sample daily schedule for campers 7:30 8:30 Early care 8:30-9:00 Drop off 9:00-10:00 Karate lesson 10:00-11:00 Fun Games 11:00-11:15 Snack 11:15-3:00 Lunch/Field trip 3:00-3:45 Karate lesson 3:45-4:00 Quick Craft 4:00-4:15 Pick up 4:15 6:00 Extended Care Our wide variety of activities include but are not limited to: Self Defense Lessons Sparring and Martial Arts Forms Board Breaking Child safety, and bully prevention Martial Arts Performances Outside Activities including Water Games, Rock Climbing, and Hiking Arts and Crafts Movies and Guest Entertainers Group Games Races and Contests ***Activities vary each week

2 Karate Adventure Summer Camp Registration Student's Name Age DOB Address Town Zip Home Phone Cell Phone Emergency Contact Phone# Rel. to student: Relevant Medical Information: Please check the weeks your child will be attending camp. Week # Dates Check Before Care After Care Week 1 June 13 June 16 (4 days only) Week 2 June 19 - June 23 Week 3 July 10 July 14 Week 4 July 17 - July 21 Week 5 July 31 Aug. 4 Week 6 Aug. 7 - Aug. 11 ***Limit: There will be a limit of 12 children on any given day. NOTE: Cost of Camp is $200 per week for 1-2 weeks, $165 per week for 3-4 weeks, and $130 per week for 5-6 weeks. NO REFUNDS will be given & no credit will be issued for unused time. Number of weeks Weekly Rate Total Amount Due: Credit Card Payment: Type Number Exp. Date CVV Amount paid Date of Payment Check Payment: Check #: Amount paid Date of Payment

3 Waiver and Release Form for Summer Camp In consideration of the acceptance of my application for the Clark's Self Defense Karate Summer Camp, I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or which may hereafter occur to me as a result of participation in said event. This release is intended to discharge in advance Clark's Self Defense Inc., its officials, officers, employees, volunteers and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assigns. Parental Consent (Complete if applicant is under 18) I give consent for my child to participate in the above activities, and I execute the above liability release on their behalf. Consent for Treatment I hereby give my consent to have the above applicant treated by emergency medical personnel, a physician, or surgeon, in case of sudden illness or injury while participating in the above activity. It is understood that Clark's Self Defense Inc. will provide no medical insurance for such treatment, and that the cost thereof will be at my expense. I have read and understood the foregoing registration liability release and parental consent form, and agree to all of its terms and conditions. Parent/Guardian Signature Print Name Date

4 Field Trip Permission I,, a parent/guardian of, give permission for my child, to participate in daily field tips organized by Clark's Self Defense as a part of the Summer Adventure Camp. Field Trip locations may include,but are not limited to Sun n' Fun, Ringling Museum, Playgrounds, Beach, Selby Botanical Gardens, Swimming Pool, Movie Theater, Indoor Amusements, Cat Depot, etc. Emergency Contact Information Child's Name Age Medical Conditions Medications required Allergies Medications required Emergency Contact Phone Physician's Name Phone I understand that I am solely responsible for providing my child with the following daily: - appropriate clothing - Karate suit - adequate lunch - water bottle - sunscreen and sun protection - bathing suit and towel - money for occasional purchases while on a field trip (optional) Please label all items. Clark's Self Defense is not responsible for any lost or stolen items. Special Instructions My child is allowed to yes no Purchase occasional items during camp yes no Walk to the restroom on his/her own or with a friend (no adult) - while on field trip yes no Sit in the front seat of a car on the way to or from trip destination Early Care and After Care will be provided at additional cost of $5.00/day Signature Print Name Date Relationship

5 Camper's Responsibilities Camper's Name In order to make Karate Adventure Summer Camp a fun, enjoyable, and safe experience for all campers, I agree to the following: I will obey all of the rules stated by Camp Staff members I will be polite and respectful to other Campers and Camp Staff I will not share/swap lunch with other Campers I will not bring any electronic devices to Camp unless permission was granted in advance I will not eat or drink in the car I will not chew gum during the Camp

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