B.E.S.T. After School Program Student Info 2018/2019


Black Belt America Presents Madison's B.E.S.T. After School Program! Building Essential Skills Today!


We are very excited to have you join the Black Belt America team! Please fill out the form below so we have all the important information on your child.


6121 Odana Rd
Madison, WI 53719
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INFO:   Please note that this form contains limited capacity items which are sold out. They are displayed grayed out and/or are not selectable. You may choose alternate options or join the waiting list.



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Registrant Fee: $0.00


Billing information


Billing and Payment
Billing and payment processing for Businesses' events is performed by Member Solutions, Inc. ("MSI"), and this contract is specifically assigned to MSI for all such purposes. Customer knowingly and irrevocably authorizes MSI to charge electronically Customer's bank account and/or credit card for any and all amounts due for Customer's, and anyone registering under Customer's, attendance and participation in the Event. Please note, you may see all or any portion of the following on your bank or credit card statement: "MSI*BLACKBELTAMERICA 8882448044 ONLINE REG FEE". Any returned payment will be assessed a $25.00 fee. Any unsuccessful electronic transaction is subject to a $10.00 processing fee. MSI is not responsible for any bank fees incurred by Customer. MSI has the sole right to resubmit returned or declined items (plus applicable fees) without prior notice. BILLING INQUIRIES -- 888-244-8044 or by mail to PO Box 297, Hatboro, PA 19040.

Applicant Agreement
I represent that I am the person who appears on the application above. I acknowledge and agree to the statements, terms and conditions above, as well as any applicable terms and conditions for this registration, and that by typing my name below and completing this registration form, I am electronically signing the document, which will have the same legal effect as the execution of the document by a written signature and shall be valid evidence of my intent and agreement to be bound.

Applicant Signature
Please enter your full name in the space below.
 


Please click the button below to finalize your registration.



Registration inquiries:
608-273-4111
info@blackbeltamerica.com
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STUDENT INFORMATION:
 
 
PARENT / GUARDIAN INFORMATION:
Monday
Tuesday
Wednesday
Thursday
Friday
 
 
SNACK OPTIONS
 
BBA provides an opportunity for students to eat snack each day when they arrive. You have two options:
 
1. Send snacks from home for your child.

2. Set up a BBA snack account for your child. In this case, we set up an account starting with a $20 charge to your account. When your account gets to $2, we will automatically process a $20 payment to replenish the account.
 
 
 
Please indicate if your child requires a booster seat in the van when transported from school to BBA. Boosters will be provided by BBA.
 
 
HEALTH HISTORY AND INFORMATION
 
If your child requires medication while at BBA, a "Medication Authorization Form" is required to be on file at BBA. This form can be filled out when you drop off the medication.
 
 


No specific medical condition
Asthma
Cerebral palsy / motor disorder
Diabetes
Epilepsy / seizure disorder
Gastrointestinal or feeding concerns including special diet and supplements
Any disorder including Cognitively Disabled
Food Allergies - specify foods
Non-food allergies - specify
 
 
 
FULL DAY POLICY:
 
If your child is 5 or 6 years old, they are in a specialized group for which we are unable to provide care when they have a full day off school.
 
On scheduled Early Release days, Black Belt America will provide a karate program for all ages.
 
(Please remember that BBA follows the Madison Public School calendar when determining when to provide a full day option or pick up for early release. After School pick up begins on September 4th.)

PLEASE READ the Terms & Conditions carefully. It is important that you understand the policies and procedures that Black Belt America has implemented.
_____ BELT PROMOTION: When a student is ready for promotion to the next belt level, a $35 test fee will be due upon completion of this test. This happens approximately every 3 months.

_____ I UNDERSTAND THAT BLACK BELT AMERICA IS A MARTIAL ARTS SCHOOL AND NOT A DAYCARE IN AS SUCH. THEIR STOCK-IN-TRADE IS NOT SUPERVISION AND CARE. THE INTENT OF BLACK BELT AMERICA IS TO TEACH MARTIAL ARTS PHYSICAL AND PHILOSOPHICAL CHARACTER BUILDING SKILLS. I UNDERSTAND THAT BLACK BELT AMERICA IS A MARTIAL ARTS SCHOOL AND IS A DROP-IN FACILITY IN AS SUCH. MY CHILD(REN) IS FREE TO COME AND GO. ADDITIONALLY, IF MY CHILD(REN) STAYS AT THE BLACK BELT AMERICA FACILITY IT IS BECAUSE OF MY DIRECTION AND NOT BLACK BELT AMERICA.

_____ I give my consent for emergency medical care or treatment to be used if I cannot be reached immediately.

_____ Waiver & Release: I understand that all possible precautions are taken to ensure that the karate programs and activities at Black Belt America are conducted by mature and qualified personnel in a safe and responsible manner. However, I fully understand that because of the nature of some activities within the karate program there is a potential for accidental injury. I do recognize these risks and agree to allow my child to participate in the karate program. I further authorize Black Belt America staff to make decisions regarding emergency medical care for my child.

_____ I grant permission to Black Belt America to use any individual or group photographs of my child(ren) taken in karate activities for publication and advertising purposes.

_____ Loss/Damage/Theft of Students Property: Black Belt America does not assume any responsibility for the loss, damage or theft of any property belonging to the student. The student agrees that Black Belt America and its personnel are not responsible for or liable for any such property even if its loss, damage or theft occurs on or about Black Belt America.


_____ I understand that Black Belt America reserves the right to dismiss any student without a refund, where conduct is detrimental to others. BLACK BELT AMERICA DOES NOT MAKE UP SICK DAYS OR GIVE REFUNDS FOR MISSED TIME.

_____ NO REFUNDS: All payments made as well as any registration fees are non-refundable. If you choose Option 1 or 4, a two week notice can be given to cancel. Payments will not be refunded if your child doesn't attend. You are responsible for all payments if you choose Options 2 or 3.

Check this box to indicate that you have read and agree to all of the above terms & conditions