Page 1 Bamboo Village Martial Arts, 8368 Brentwood Blvd, Brentwood CA, 94513 925-634-4686, www.thebamboovillage.com BAMBOO VILLAGE MARTIAL ARTS AFTER-SCHOOL STUDENT ENROLLMENT FORM SECTION 1: STUDENT INFORMATION 20___-20___ SCHOOL YEAR NAME DATE OF BIRTH GRADE AGE ALLERGIES Y / N ADDRESS *NAME OF SIBLINGS BEING ENROLLED AGE /GRADE OF SIBLINGS BEING ENROLLED SECTION 2: PARENT/GUARDIAN INFORMATION NAME RELATIONSHIP TO CHILD ADDRESS IF DIFFERENT THAN STUDENT CONTACT INFORMATION HOME PHONE CELL PHONE BUSINESS PHONE EMAIL ADDRESS SECTION 3: SCHOOL INFORMATION NAME OF SCHOOL SCHOOL HOURS ADDRESS PHONE NUMBER SECTION 4: DAYS STUDENT ATTENDING AFTERSCHOOL PROGRAM ENTIRE WEEK YES NO PARTIAL WEEK (Please circle days Attending) Monday Tuesday Wednesday Thursday Friday SECTION 5: PERSON 9S AUTHORIZED TO PICK UP STUDENT (Identification will be required if person other than parent is picking up student and must be at least 18 years of age 3 NO EX CEPTIONS) NAME ADDRESS RELATIONSHIP TO CHILD Page 2 Bamboo Village Martial Arts, 8368 Brentwood Blvd, Brentwood CA, 94513 925-634-4686, www.thebamboovillage.com SECTION 6: PERSONS NOT AUTHORIZED TO PICK UP STUDENT (Please provide copy of court order) NAME ADDRESS RELATIONSHIP TO CHILD SECTION 7: EMERGENCY CONTACT INFORMATION (If parents cannot be reached) NAME PHONE NUMBERS RELATIONSHIP TO CHILD SECTION 8: ... more. less.
MEDICAL INFORMATION Current health issues: Current medications Social/Special Needs/Other Physician 9s Name Phone No. Health Insurance Co. Policy No.<br><br> SECTION 9: OTHER Please list any other information/concerns for your child: SECTION 10: SIGNATURES _________________________________________________________ PARENT/ GUARDIAN SIGNATURE DATE____________________ ADMIN ONLY : ____________ Copy of Terms and Conditions Given to Parents ___________ Parent Letter Medical Issues____________________ Court Orders________________ Sibling Enrolled_______________ Name of Sibling(s)_______________ Class Registration ____________ Entire Week __________ Partial Week ______________ Other Dojo Software ____ QuickBooks_____ Waiver Signed _____ Dojo _____ Medical Treatment _____ Transportation ____ Automatic Payments _____ Registration Fees Page 3 Bamboo Village Martial Arts, 8368 Brentwood Blvd, Brentwood CA, 94513 925-634-4686, www.thebamboovillage.com TERMS AND CONDITIONS OF ENROLLMENT BAMBOO VILLAGE IS NOT A DAY CARE/CHILD CARE CENTER - WE ARE AN AFTER SCHOOL MARTIAL ARTS PROGRAM. AFTER SCHOOL MARTIAL ARTS PROGRAM PRICES : Uniform $25.00/one time Registration Fee $45.00/one time Elementary Age (K-5) " 5 times a week 2:30 to 6:00 pm $100.00/week " 2-3 times per week 2:30 to 6:00 pm $80.00/week Middle School (6th, 7th & 8 th ) " 5 times a week 3:30 to 6:00 pm $75.00 " 2-3 times per week 3:30 to 6:00 pm $55.00 When school is dismissed early (Noon 3 6:30 pm) Free for full time students $0 Part Time Students $10.00 When school is closed all day (NA) * Additional family members enrolled in the Bamboo Village Martial Arts After School Program receives a 20% Discount per child. A NOTE ABOUT THE UNIFORM The (gi) uniform is to be treated with respect.<br><br> This shows unity and pride in our school and oneself. The uniform should be kep t clean and neat at all times. Please be sure to put your child 9s name on the inside waistband of the pants and on the inside co llar of the top.<br><br> TESTING FEES AND EQUIPMENT As in any sport there is equipment and uniforms to purchase. Martial arts is no exception! Every 3-4 months, depending on your child 9s skills and level of preparation, there will be a belt testing.<br><br> In order to be eligible to test, you must pay the testin g fee at least one session prior to your child 9s testing date; Testing fees vary, depending on the belt color. The cost begins at $25 and vari es by rank. PAYMENT AND PICK UP INFORMATION 1.<br><br> Automatic payments are processed on the 1 st of the month for the upcoming month. Method of Payment is via automatic payments with Visa or MasterCard. 2.<br><br> Pick up time for the after school program is 6:00 p.m . If you are going to be later than 6:00 p.m. please call Bamboo Village at 925-634-4686.<br><br> There will be a late pick up fee of $10.00 per half hour. If you need extended pick up time it will be $5.00 per half an hour, early arrangements must be arrange for extended pick up. 3.<br><br> If your child takes a break from the program (other than during the holiday season or summer vacation) there will be an additional registration fee due when they resume the program. 4. When schools are closed for Federal or Non-Federal Holidays, we will credit $20 for that day in the following month 9s payment.<br><br> 5. There will be no refunds or adjustments on winter break or spring break. Page 4 Bamboo Village Martial Arts, 8368 Brentwood Blvd, Brentwood CA, 94513 925-634-4686, www.thebamboovillage.com PARENT 9S RESPONSBILITY CHECKLIST 1.<br><br> You must come in and sign your child out! 2. Notify your school that Bamboo Village Martial Arts After School Program will be picking up your child.<br><br> 3. Make sure your child is wearing his/her nametag the first two weeks until the instructors become familiar with all children. 4.<br><br> If your child does not go to school because he/she is sick, etc., you MUST notify us as soon as possible so that we can notify all drivers. 5. Payments are made in advance the month prior for the upcoming month of pickup.<br><br> 6. There will be no adjustments for days not attended unless we receive 2 week 9s notice of the attendance change. 7.<br><br> Check our lost and found weekly if your child has lost any items. 8. Please be sure to write your child 9s name on the inside waistband of the pants, and the collar of the top.<br><br> Equipment and belts must also be marked. 9. If you wish to cancel the program, we must have a 30-days written notice .<br><br> 10. If you have an exorbitant amount of absences you are still liable to pay for that week unless you have a written doctor 9s note. RULES FOR STUDENTS 1.<br><br> Be at the appropriate place at pick-up time. 2. Behave and buckle up in the van/car.<br><br> No Horseplay! 3. Change into your uniform promptly for class.<br><br> 4. Put your things in the changing room, and back in your book bag. 5.<br><br> Do your homework. Be quiet and respectful of others who are also doing their homework. If you have a question or need help, raise your hand.<br><br> 6. No running. 7.<br><br> Use inside voices. 8. Outside of class time, do not TOUCH, PUNCH, HIT, KICK, PINCH (or any other form of contact) another student or instructor.<br><br> 9. Follow all instructions and directions that are given by your instructor. 10.<br><br> No bad language or name-calling is allowed. DISCIPLINE POLICY Bamboo Village Martial Arts After School Program is a program based on the contract between Parents or legal guardian and their children for taking Martial arts classes . In order to maintain a safe and quality program, we occasionally find it necessary to discipline a student.<br><br> We feel that effective and positive ways of behavior management are: 1. REDIRECTION: We will stop the child and calmly learn what has happened, why and how they see it, and then suggest other ways of handling the situation. Then, we will redirect their attention.<br><br> 2. SEPARATION: We will have the child play apart from the rest of the group and rest for a short time. This gives them an opportunity to calm down.<br><br> Then we will explain other ways of good behavior. 3. PARENT CONFERENCE: If a child 9s behavior remains problematic, a parent conference will be held.<br><br> If there is little or no improvement in the child 9s behavior after the parent conference, termination of enrollment may become necessary. 4. TERMINATION: Termination of enrollment will be at the discretion of Bamboo Village Martial Arts After School Program Administrative Staff.<br><br> PARENT/GUARDIAN 3 Please initial and sign below: _______ I have read, understood and agree to the uniform requirements _______ I have read, understood and agree to the testing fees and equipment policy _______ I have read, understood and agree to the pricing policy _______ I have read, understood and agree to the payment deadline policy _______ I have read, understood and agree to the parent 9s responsibilities _______ I have read, understood and agree to the rules for students _______ I have read, understood and agree to the discipline policy ___________________________________________________________ Parent/ Guardian Signature DATE____________________ Page 5 Bamboo Village Martial Arts, 8368 Brentwood Blvd, Brentwood CA, 94513 925-634-4686, www.thebamboovillage.com RELEASE AND WAIVER AGREEMENT My name is __________________________________ and I am the parent/guardian of _________________________________________. I am entering into the following Release and Waiver Agreement with Bamboo Village Martial Arts, Justin LaVasse, and all other instructors of the martial arts at Bamboo Village Martial Arts, as well as my fellow students in the martial arts classes / self defense clinics / / after school programs/ seminars or other functions that I am participating in. I understand that I am signing this Release and Waiver Agree ment in consideration for and as a requirement of my participating in any Bamboo Village martial arts classes / self defense clinics / after school programs, seminars or other functions whether located at or through any Bamboo Village Martial Arts facility or other location(s).<br><br> For myself, my successors, heirs or assigns and legal representatives, I do now and forever, fully and finally, re lease, discharge and waive from any and all claims, demands, damages, expenses, costs, actions or causes of actions known or unknown, past, present or future from any personal injuries including bodily injury or death which are alleged to have arisen out of or resulted from my participation in any martial arts activity including, but not limited to, exercises, drills, and sparring all the above named individuals, entities and corporations. I understand that the participation in martial arts activities includes a risk of serious personal injury or even death. I know that martial arts are a contact endeavor, and I understand that I am responsible for evaluating my own physical condition and abilit y to participate in the martial arts classes.<br><br> By my signing this Release and Waiver Agreement, I am stating that I have the physical ability and health to participate in those martial arts classes. If I am a minor under eighteen years of age, I am certifying by signin g this Release and Waiver Agreement that I have had my parent or legal guardian also sign this Release and Waiver Agreement signifying that they are also entering into this Release and Waiver Agreement as well as consenting to my signing the same. This Release and Waiver Agreement executed this ______ day of ______________, 200___.<br><br> _______________________________________________ Phone No.__________________________________ Parent/Guardian Signature Address:____________________________________ _____________________________________ AUTHORIZATION AND URGENT CARE WAIVER I hereby authorize Bamboo Village Martial Arts to act on my behalf in an emergency requiring medical attention or any other hum ane action. I herby waive and release Bamboo Village Martial Arts, and any and all officers, directors, employees, volunteers and f ellow students and from all liability for any injuries or illnesses incurred. I understand that participation in martial arts classes and all other activities inside and outside the Bamboo Village Martial Arts School involves physical activity and as such carries with it the risk of injury.<br><br> Should an injury occur, any and all medical e xpenses incurred are the sole responsibility of the participant or participant 9s family, this includes all activities inside and out si de this facility. I have documented below all precautions and instructions regarding my child 9s medication _______________________________________________________________________________________________________________________________ __ _______________________________________________________________________________________________________________________________ __ Student Name _____________________________ Parent or Guardian Name _____________________________ Parent/Guardian Phone Number:____________________________________________________________________ Parent or Guardian (Signature) _____________________________ Date ________________ PERMISSION TO RIDE FORM /AUTHORIZATION OF TRANSPORTATION I hereby authorize Bamboo Village Martial Arts to transport my child to and from school, to medical facilities, including urgen t care and hospital facilities, and any other places visited from time to time. Student Name _____________________________ Parent or Guardian Name ____________________________________ Parent or Guardian (Signature) ___________________________________________________ Date _______________<br><br>