Martial Arts America: 2023 Summer Karate Camp Registration Form

Summer Karate mini-camps Information Form

We're excited for the upcoming Karate Summer Camps.

Kids love our summer camps and this mini-camp is full of action and fun! For ages 6 � 12 years old, your child will have a blast learning and practicing karate skills, games, crafts, obstacle courses, indoor and outdoor activities and lots more. No experience in martial arts is needed.

Camp days are Monday through Thursday from 9 am � 3 pm (early drop off starts at 8:00 am and late pickup by 5:15 pm)

$225/week

Early drop-off/late pickup $30/week

Campers bring their own lunch and snack.

There are 4 Camp weeks available this year

Camp Themes and locations:

Camp week 1 Ninja Week - 6/26-6/29 All Martial Arts America dojos (Brighton, Penfield and Webster)

Camp week 2 Power Week - 7/10-7/13 - Penfield location - 2160 Penfield rd.

Camp week 3 Samurai Week - 7/17-7/20 - Webster location - 1270 Creek St.

Camp week 4 Challenge Week - 7/24-7/27 Martial Arts America, 3450 Winton Place plaza, Rochester

Camp starts at 9:00 am (early drop off is available)

Camp ends at 3:00 pm (late pickup is available)

Please send your child with a lunch, drink and snacks (2). Extra water is recommended.

Campers should wear regular clothing (not karate uniforms). Outdoor active footwear is recommended (not flip flops).

We may go outside for some activities so please apply sunscreen to your child as needed.

Event Date

June 26 - July 27, 2023

Venue

Martial Arts America
Brighton - 3450 Winton Place, Rochester, NY
Penfield - 2160 Penfield rd., Penfield, NY
Webster - Bay Towne Plaza, Webster, NY

INFO:

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When would you like to pay?

Registrant Fee:		$0.00
Group Fee:		$0.00
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Billing information

First Name

Last Name

Country

Address

City

State/Province

Zip/Postal

Phone

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*MARTIALARTSAMERICA 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:
Matt Dorsey
mdorsey@rochesterkarate.com;
(585) 475-9250
3450 Winton Place
Rochester, NY 14623

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Registrant

use this registrant for billing information

Which Camp week(s) are you registering your child for?

June 26-29 - Brighton and Penfield locations
July 10 - 13 - Penfield branch
July 17 - 20 - Webster branch
July 24 - 27 - Brighton branch

Which location will you be attending (week 1 only)

Child's First Name

Child's Last Name

Parent name(s)

Parent Mobile Phone

Additional emergency contact name (not the same as parent above)

Emergency contact Phone

Parent's Email

Authorized Person(s) for pick-up (other than parent) - give name and relationship (i.e. Joe Smith - uncle)

Do you need early drop off? (8 am is earliest drop-off time)

Which days do you need early drop-off and times? (Monday, Tuesday, Wednesday, Thursday)

Do you need late pickup? (5:15 pm is latest pickup)

Which days do you need late pickup and times? (Monday, Tuesday, Wednesday, Thursday)

Please list allergies and any other medical conditions

Any else you'd like us to know about your child?

Physician's name and telephone number

Preferred Hospital

I understand that the study of Karate, jiujitsu and other martial arts requires physical contact in many contexts including, but notlimited to, sparring, hand-to-hand combat and self-defense techniques and alsoacknowledge that injury is an inherent potential result of any suchactivity. I also represent that I ammedically and physically able to participate in the exercises and physicaldemands of the discipline. I also agree thatany injuries or limitations will be made known immediately. I also understand that there is no guaranteefor my personal safety after the completion of this course. In view of the foregoing and as a term andcondition of being a student of Martial Arts America, I, with the intention of bindingmyself, my spouse, heirs, legal representatives, and assigns, expressly releaseand discharge Martial Arts America, their owners, employees and legalrepresentatives from all claims, demands, actions, judgments and executionsthat I ever had, or now have or may have or that anyone claiming through himmay have or claim to have, against Martial Arts America, their owners,employees or legal representatives created by or arising out of any and allclass activity regardless of where held or when held. Also, I agree to allow,without compensation, the unrestricted use of any photographs, films orvideotapes of myself. In witness whereof, I execute this release on this dayand year written below.
I hereby give my permission to the medical personnel selected by the Day Camp Coordinator to order x-rays, routine tests, treatments, and necessary transportation for the child named above. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Day Camp Coordinator to secure and administer treatment, including hospitalization, for the child named above.

Signature typed here constitutes a legal and binding signature.

Parent Name

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