After School

* ALL forms must be filled out.

Download all After School Forms (zip archive)

Cape Fear Isshin-Ryu After School Karate Program REGISTRATION FORM

Our after school program is being offered for children ages (5-14) between 2:00-6:15 P. M., Monday through Friday. Transportation is available from specified local schools to Cape Fear Isshin-Ryu Karate & Afterschool Program. There will be designated time for homework, Karate instruction, snacks and games.

Registration Form for Cape Fear Isshin-Ryu After School Program

I agree to waive any and all claims against persons connected with Cape Fear Isshin-Ryu Incorporated.
As we are aware, very young children are prone to mishaps. Although we will give every effort to have adequate supervision, occasionally accidents will happen. In the instance that an emergency arises we would consider this form your specific permission to transport and have your child treated by a professional caregiver/physician, etc. This form also serves as specific permission to pick your child up from their respective school and transport them back to our dojo for our karate after school program. Cape Fear Isshin-Ryu reserves the right to remove any child from the program. This is for the safety and well being of all students and staff.

NO REFUNDS AFTER REGISTRATION

2 WEEKS WRITTEN NOTICE IS REQUIRED IF YOU WISH TO WITHDRAW FROM THE PROGRAM

Parent Signature:*
- Yes
Date:*
Student Information:
Student Name:*
School:*
Grade:*
Date of Birth:*
Parents Name:*
Home Address:*
Phone Home:
Phone Work:
Phone CELL:*
Email address:*
Emergency contact, NAME:*
Phone:*
Relation to student:*
Family physician name/address/phone #*
Insurance Company:*
Policy #*
Phone #*
Transportation Permission:
From time to time, it may be necessary to transport a camper/after school Student to an event or from school via staff passenger vehicle. Therefore, we must have your permission to transport your child in such vehicles as circumstances warrant. Your signature below authorizes us to do so as required. In addition, I authorize my child/children to be transported to and from camp activities/school via Cape Fear Isshin-Ryu Incorporated vehicles. By signing this, I am also giving my permission to send my child/children on any prearranged field trips.
Parent Signature:*
- Yes
Date:*

Cape Fear Isshin-Ryu Medical Information Form

Name of student: *
Age:*
Parent/Guardian Information:
Name:*
Relation to student: *
Phone Home:
Phone Work:
Phone CELL:*
Address:*
City:*
State:*
Zip:*
Emergency Contacts:
Name:*
Phone:*
Relation to student: *
Name:*
Phone:*
Relation to student: *
Does your child have any restrictions to his/her participating in training in the martial arts or a physical excersice program? Yes or no.
- Yes
If yes, Please explain:
Does your child have any allergies or medical conditions that we should be made aware of? Yes or no.
- Yes
If yes, please explain:
Family Doctor name/address/phone:
Family Doctor name/address/phone:*
Insurance information:
Provider:*
Policy #*
Consent & Release Form
In the event I cannot be reached in an emergency, I hereby give my consent to Cape Fear Isshin-Ryu, its instructors, employees, or any Emergency Medical Personnel to administer or secure any necessary treatment to my child (named above) in the event of an emergency and transport him/her by ambulance if the situation warrants.*
- Yes
I understand that karate and all other Martial Arts are sports involving physical contact and physical exercise. I am aware that my child is engaging in physical exercise and self defense instruction. I understand that it is advisable to contact my child’s physician before entering any physical fitness program. My child is voluntarily participating in these activities. *
- Yes
Parent/Guardian authorization: *
- Yes
Date:*

Cape Fear Isshin-Ryu Rules of Conduct Memorandum of Understanding

The following is a list of rules for our After School Program. We can not list every act a child could conceivably engage in. This should serve as a general list. We reserve the right to remove a child without prior notification who in our sole discretion is unable to fit into our program.

STUDENTS SHALL NOT BE PERMITTED TO ENGAGE IN THE FOLLOWING CONDUCT:

The use of obscene or profane language, or any acts, gestures, or innuendo directed at any student or staff member.
The use of any derogatory language; referring to the color, religion, ethic origin or any aspects of a person’s character, custom and/or heritage.
An act of dishonesty, deception and/or related behavior.
Failure to follow instructors’ or counselors’ instructions (repeatedly).
Not following safety rules (e.g. unbuckling safety belts, jumping or running in unauthorized areas)
The possession of any narcotic, drug or other controlled substance other than those authorized by parents and/or doctor.
The possession of any firearm, weapon, or any item that resembles a weapon.
Threatening another student, through intimidation, either verbal or non-verbal.
Destruction of Cape Fear Isshin-Ryu property, or the property of other students or staff.
Touching or physical horseplay, this behavior is strictly prohibited because of the possibility of injury or physical altercations.
Borrowing or lending money.
Any acts that can cause injury to students, facilities, property, staff members, etc.

I HAVE READ AND UNDESTAND THE ABOVE POLICY REGARDING RULES OF CONDUCT FOR
CAPE FEAR ISSHIN-RYU

Cape Fear Isshin-Ryu Waiver Agreement

Release of Liability

I hereby waive and release any claim or rights to sue Cape Fear Isshin-Ryu, it’s agents, officers, students, instructors, employees, volunteers and management from any and all injuries that may occur on or off these premises through negligence or not, while participating, practicing, watching or competing in Karate or any other event or program. Students and their guests in using the dojo and any equipment, do so at their own risk. Cape Fear Isshin-Ryu, its agents, officers, students, instructors, employees, volunteers and management shall not be liable for any damages arising from personal injuries sustained by students and their guests, in, on, or about the premises of the dojo. The dojo assumes no responsibility for loss of, or damage to, any personal property belonging to student or guest while on the premises.

I understand that while in regular Karate or any events or programs, my child may be engaging in activities (karate, martial arts training, dodge ball, etc. ) and that these activates may have risks and hazards inherent to the type of activity or use of certain equipment or the facilities themselves. As we are aware, young children are prone to mishaps. Although we will give every effort to have adequate supervision, occasionally accidents will happen. In the instance that an emergency arises we would use this form as your specific permission to transport and have your child treated by a professional caregiver/physician, etc.

In signing this consent form, I hereby acknowledge and represent that I have read the foregoing, understand its terms, and sign it voluntarily. I also acknowledge that my child/children is in excellent physical health and is able to endure strenuous recreational activates and play, including the above named activities and others not mentioned or stated. Students represent that he or she is in good physical condition and able to use the equipment provided and to participate in program made available by the dojo. The dojo represents that its personnel are trained in providing equipment and instruction.

I have read and agree with all the above. I agree to waive any and all claims against persons connected with Cape Fear Isshin-Ryu.

Cape Fear Isshin-Ryu After School Karate Program REGISTRATION FORM

Registration Form for Cape Fear Isshin-Ryu After School Program

NO REFUNDS AFTER REGISTRATION

2 WEEKS WRITTEN NOTICE IS REQUIRED IF YOU WISH TO WITHDRAW FROM THE PROGRAM

Student Information:

Transportation Permission:

Cape Fear Isshin-Ryu Medical Information Form

Parent/Guardian Information:

Emergency Contacts:

Family Doctor name/address/phone:

Insurance information:

Consent & Release Form

Cape Fear Isshin-Ryu Rules of Conduct Memorandum of Understanding

STUDENTS SHALL NOT BE PERMITTED TO ENGAGE IN THE FOLLOWING CONDUCT:

I HAVE READ AND UNDESTAND THE ABOVE POLICY REGARDING RULES OF CONDUCT FOR
CAPE FEAR ISSHIN-RYU

Cape Fear Isshin-Ryu Waiver Agreement

Release of Liability

Cape Fear Isshin-Ryu After School Karate Program Pick Up Permission

List of people that can pick my child up:

Cape Fear Isshin-Ryu After School Karate Program REGISTRATION FORM

Registration Form for Cape Fear Isshin-Ryu After School Program

NO REFUNDS AFTER REGISTRATION

2 WEEKS WRITTEN NOTICE IS REQUIRED IF YOU WISH TO WITHDRAW FROM THE PROGRAM

Student Information:

Transportation Permission:

Cape Fear Isshin-Ryu Medical Information Form

Parent/Guardian Information:

Emergency Contacts:

Family Doctor name/address/phone:

Insurance information:

Consent & Release Form

Cape Fear Isshin-Ryu Rules of Conduct Memorandum of Understanding

STUDENTS SHALL NOT BE PERMITTED TO ENGAGE IN THE FOLLOWING CONDUCT:

I HAVE READ AND UNDESTAND THE ABOVE POLICY REGARDING RULES OF CONDUCT FORCAPE FEAR ISSHIN-RYU

Cape Fear Isshin-Ryu Waiver Agreement

Release of Liability

Cape Fear Isshin-Ryu After School Karate Program Pick Up Permission

List of people that can pick my child up:

I HAVE READ AND UNDESTAND THE ABOVE POLICY REGARDING RULES OF CONDUCT FOR
CAPE FEAR ISSHIN-RYU