Kokoro Kai Summer Karate Camp Application
Session: June 20-24
Session: July 18-22
Session: August 8-12
**Please note that the camp fee is neither refundable after the deadline**
Late enrollment accepted with a $20.00 extra charge
Camper's First Name
Camper's Last Name
This is a registration form for:
Gender:
Age
Present Rank
Home Address
Emergency Contact / Parent:
(Day)Name
phone
Does the Camper have any special Needs?
(Medications, serious allergies, etc. If “YES,” please list an explanation below
Kokoro Kai Karate Camp Waiver

Carefully read the waiver, below. Please check "I Accept" below to accept the waiver. 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".

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 East Montgomery Karate Academy, LLC, 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 in this Camp. I herby waive all claims against the owners, directors, and staff of the Kokoro Kai, LLC Association and/or the East Montgomery Karate Academy, LLC 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 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 as had physical examination by a licensed medical doctor within the past year and has no infirmities and/or disabilities that would prohibit him 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, 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 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, 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 Kokoro

Kai, LLC Association, East Montgomery Karate Academy, LLC and/or Gladstone Karate Academy, in defense of any claim or action.


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.

I Accept