Deerfield Community Center

Youth Karate-Do

Session III

2008 Registration

 

 

Please Check Class for Enrollment:

 


 

A.           Rookie (No Karate Experience)

Fridays 3:10-3:40PM  Cost: $ 25

 

B.____ Novice (5-7 yrs. old, with karate experience)

Fridays, 3:10-3:40 p.m. Cost:  $25

C._____ Continuing I (6 yrs. and up)

Wed. and Fri, 3:45-4:30 pm Cost:  $42

D.            Continuing II (Exp or Inst. Permission)

Wed. and Fri.,  4:30-5:15 PM

Cost:  $42

 

Participant’s Name                                                        Grade              Age              Gender                      

 

 

Have you registered in 2008?  Yes                       (if YES, STOP AND SIGN BELOW)  No                                

 

Address                                                                             City                                       Zip                           

 

Medical Information                                                                                                                                       

 

Parent/Guardian's Name                                                                                                                              

 

Home Phone                                     Cell Phone                                    Email                                             

 

IMPORTANT

Participation Waiver

Please read and sign the following

I, the parent/guardian of the registrant, a minor, agree that the registrant and I will abide by the rules of the Deerfield

Community Center (the "DCC"), its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with youth programs (the "Programs") and in consideration for the DCC accepting the registrant for its Programs and activities, I hereby release, discharge and/or otherwise indemnify the DCC, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize. As the parent or legal guardian of the above-named player, I hereby give consent for emergency medical care given under whatever conditions are necessary to preserve the life, limb or well being of my dependent.

 

                                                                                                                                                                     

Printed Name of Parent/Legal Guardian                   Signature                                              Date                                  

Text Box: IMPORTANT Participation Waiver Please read and sign the following I, the parent/guardian of the registrant, a minor, agree that the registrant and I will abide by the rules of the Deerfield Community Center (the "DCC"), its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with youth programs (the "Programs") and in consideration for the DCC accepting the registrant for its Programs and activities, I hereby release, discharge and/or otherwise indemnify the DCC, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize. As the parent or legal guardian of the above-named player, I hereby give consent for emergency medical care given under whatever conditions are necessary to preserve the life, limb or well being of my dependent.                                                                                                                                                                         Printed Name of Parent/Legal Guardian                   Signature                                              Date                                    

 

 

 

 

 

 

 

 

 

 

 

 

 


 

Please make checks payable to DCC

Please return form and fee to:

Deerfield Community Center 3 W Deerfield St. or by mailing to PO Box 404 Deerfield, WI 53531