Gasshuku Registration

Kokoro Kai Gasshuku Application

Camp Nock-A-Mixon

June 2, 3, 4 (Friday 4 PM to Sunday 12 PM

Early Registration is $250, Deadline Feb 28 2017

Normal Registration is $275, Deadline May 15 2017

All tuition and registration must be received by this date. No exceptions.

To register for camp, please fill out the following form. Then use the PayPal button to complete the transaction.







Emergency Contact/Parent

Kokoro Kai Karate Camp Waiver

Carefully read the waiver, below. Please check "I Accept" below to accept the waiver. Camp applications turned in later than the deadline will not be accepted.  See Mr. Exaros or Mr. Parisi for details or any questions. 

As used below, "I" means the parent, parents, and/or legal guardian of the child intending to participate in the summer camp discussed below."Child" means the child who will attend the camp, sometimes referred to as "Camper". 

I hereby voluntarily submit my/my child's application for summer camp to be held at the Camp Nockamixon, Kintnersville, PA as sponsored by Kokoro Kai, LLC.  I assume full responsibility for any and all injuries, damages and losses (personal injury and/or property damage) that may be incurred by, or caused by, myself/my child while attending, participating or traveling to or from the camp location.  I hereby waive all claims against the owners, directors, and staff of the Nockamixon Camp as well as those of the Kokoro Kai, LLC Association and/or the East Montgomery Karate Academy, LLC and Gladstone Karate Academy, including negligent acts and/or omissions on their parts, their agents, servants and/or employees, individually, jointly, severally, or in the alternative. 

I agree to hold harmless and indemnify the Kokoro Kai, LLC Association, East Montgomery Karate Academy, LLC and/or Gladstone Karate Academy for any and all claims against them filed by any third party and/or entity including other participants in the summer camp, whether for personal injuries and/or property damage where such damages were caused in whole or in part by the acts and/or omissions of myself or my child. 

I certify that the above applicant is medically, physically, and emotionally capable and prepared to participate in this camping program.  I further certify that the child has had physical examination by a licensed medical doctor within the past year and has no infirmities and/or disabilities that would prohibit him/her from attending and/or participating in the summer camp.  I understand that available medical treatment will be of a first aid type only, but that in case of emergency, the Camper will be taken to the closest hospital emergency room and that, to the extent possible, the permission of a minor's parent or guardian must be obtained before any treatment will be given. 

I agree to hold harmless and indemnify Kokoro Kai, LLC Association, East Montgomery Karate Academy, LLC and/or Gladstone Karate Academy, its agents, servants and/or employees, from any claims for damages arising out of any first aid treatment rendered by Kokoro Kai, LLC Association, East Montgomery Karate Academy, LLC and/or Gladstone Karate Academy, its agents, servants and/or employees, including the negligent acts and/or omissions of said entities and/or personnel. Further, I agree to hold harmless and indemnify Kokoro Kai, LLC Association, East Montgomery Karate Academy, LLC and/or Gladstone Karate Academy, its agents, servants and/or employees with regard to any claims for damages arising out of the treatment rendered by any hospital, medical provider, doctor, nurse, emergency treatment personnel, etc., with regard to the Camper.  I understand that all hold harmless and indemnification clauses include indemnification for attorney's fees and legal costs incurred by KokoroKai, LLC Association, East Montgomery Karate Academy, LLC and/or Gladstone Karate Academy, in defense of any claim or action.

I also understand that in the event of an injury or incident involving my child, the camp staff will contact me to inform me of such incident no matter how minor and as soon as is practicable. 

I acknowledge that the Camper is fully responsible for his/her own conduct and that all rules, regulations and verbal direction by the staff must be strictly obeyed.  I hereby grant the staff permission to take such measures as they may deem necessary to maintain safety and discipline.  I understand that these may include, but not be restricted to, curtailment of activity or expulsion form camp for which no refund will be given.  I acknowledge that, should any unobserved incident occur, it is the Camper's sole responsibility to immediately bring it to the attention of the staff.  I further acknowledge that the staff shall not be held accountable for any incident or situation of which it was not made aware; that proper supervision does not include constant surveillance; and that I will accept as satisfactory the staff's sole judgment in determining the resolution of any problem. 

I understand and acknowledge the physical, mental, and emotional nature of the activity to be conducted at the summer camp. I represent that I have been given the opportunity to ask questions prior to the summer camp beginning concerning (a) the nature and extent of the activities of the summer camp, (b) the experience of the instructors and camp supervisors, and (c) the condition of the facilities and surrounding areas. Any inquiries or questions that I had have been answered thoroughly and to my satisfaction.

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