MJTKD Summer Camp 2025

*PLEASE USE STUDENT INFORMATION TO FILL OUT FORM*

• Child First Name

  Child Last Name
  

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  Make Required
• Birthday
  

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• 2nd Participant First Name

  2nd Participant Last Name
  2nd Participant Birthday
  Add Another Participant
  
• Street Address
  Address Continued
  City

  State/Province
  Postal Code
  

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  Make Required
• Gender MaleFemaleOther
  

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• Mom/Guardian First Name

  Mom/Guardian Last Name
  

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• Mom/Guardian Mobile Phone

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  Make Required
  
• Job Title
  

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• Dad/Guardian First Name

  Dad/Guardian Last Name
  

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• Dad/Guardian Mobile Phone
  

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  Make Required
• Email Address

  

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  Make Required
• Emergency Contact Name

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  Make Required
  
• Emergency Contact Phone
  

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  Make Required

• The child will be released to the person(s) authorized, by the custodial parent(s) or legal guardian(s). The following people are authorized to remove the child from the facility in case of illness, accident, or emergency, if for some reason the custodial parent(s) or legal guardian(s) cannot be reached:

  
• Authorized Persons/Phone for Child Pick-Up:

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• Please list all identifying scars, birthmarks, skin discolorations:

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• Special needs of child/ habits/ fears/ etc.

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• Marketing Source Booth EventBuddy WeekDemonstrationFacebook adGrouponGuest of a Current MemberInfo CallMagazine AdParent's Night OutRank Promotion GuestSchool TalkWalk In
  

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• Permission To Ride:

  I (We) hereby grant permission for my child(ren) to ride to and from the tkd studio and/or all field trips and events sponsored by Mt. Juliet Tae Kwon Do, Inc.*  *Students will be traveling in 12 or 15-passenger vans, a 28-passenger bus, or private passenger vehicles.  All vehicles are fully insured and are driven by a paid staff member of Mt. Juliet Tae Kwon Do, Inc.   I authorize school representatives to obtain medical treatment for my child in case of serious illness or injury and agree to pay for such treatment. 

  
• Yes I agree to the "Permission to Ride" terms listed above for my child(ren)

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  Yes I agree to the "Permission to Ride" terms listed above for my child(ren)

• Photo Waiver:

  Mt. Juliet Tae Kwon Do, Inc. (MJTKD) has photographed different moments and events that take place in the school or when traveling.  MJTKD would like to post these pictures to a photo galleria on the school website at mjtkd.com and/or Facebook or other advertising avenues.  In order to post a child’s picture on the website, a photo waiver needs to be signed by anyone over the age of 18 or, for those under 18, a parent/guardian needs to sign the form.  If there is a group photo, a waiver needs to be signed by every child in the photo.  Photographs taken at MJTKD may be used in future public materials (including but not limited to posters, brochures, advertisements, videos, and the website). Please complete the following if over the age of 18.  If not, parent/guardian must complete: I hereby give permission to Mt. Juliet Tae Kwon Do, Inc. to use any and all photographs taken of me and/or my child(ren) for posting the website or on printed materials.  I hereby waive any rights or interest that I might have in any or all images. 

  
• Yes: I give permission to us any and all photographs taken for posting on social media and/or printed materials

  No: I prefer my child not be included on social media and/or printed materials

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  Yes: I give permission to us any and all photographs taken for posting on social media and/or printed materials,No: I prefer my child not be included on social media and/or printed materials

• Release for Emergency Care:

  I hereby give my consent to any emergency facility and physician to administer necessary treatment to my child in the event of an emergency at which time I cannot be reached.  I give consent to transport by ambulance if situation warrants.

  In the comment box below, please provide the following information:

  1) Family physician name/Health Care Resource and Phone

  2) Allergies

  3) Date of last DPT or Tetanus

  4) Insurance company covering child and Insured's Name

  5) Policy number

  6) Group number

  
• Please list the info for emergency care:

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• Waiver                                     

  AGREEMENT/ACKNOWLEDGEMENT OF RULES & REGULATIONS

  The Parent Waiver/Rules & Regulations (Agreement) is between the authorized person or persons signing this Agreement (“You” and “Your”) and Mt. Juliet Tae Kwon Do, Inc.  You agree to all the terms and conditions, in this Agreement.

  We are not a daycare, nor do we provide primary insurance

  I (We) have read and agree to the Terms and Conditions of this Agreement, provided digitally.  I further agree and understand my child(ren) can and will be removed from the program if any of the rules are not complied with.  You further agree to hold Mt. Juliet Tae Kwon Do, Inc. (herein called “school”) and/or any of its nominees, harmless from and against any and all liability as to any problems that could arise.  Regardless of fault, the school is not responsible for loss of or damage to any property left behind by your child.  You hereby assume all risks of such loss or damage and agree to defend, indemnify, and hold the school harmless of all claims.  You understand and agree that you will pay for any and all costs and/or expenses of any kind of damages, if any that may be caused by your child (ren).

  You agree that your insurance coverage, if valid and collectable, will be primary and responsible for handling, defending, and paying all third-party claims, if any, should they arise.  The school does not provide you or your child primary insurance coverage.

   I (We) am/are aware of and agree to:  

  *MJTKD drop-off & pick up times       

  *Sick Child Policy

  *Program Attendance Policy               

  *Lunch/Snack Policy

  *Transportation Policy                        

  *Fees/Tuitions/Refund Policy

  *Emergency Care Policy                                

  *Photo Waiver Policy

  *Permission to Ride Policy

                                                         

                Signature of Authorized Parent or Guardian                                       

  

  Sign above

  ClearUndo
  

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