Camp & Event Registration Form COVID-19 Studio Safety Protocol COVID-19 Day Camp Safety Protocol Camp & Class Registration Form Choose Event Event * 1 - $39 per Week Zoom Class Special 2 - Oct 19th - Oct 23rd Lego Challenge & Mega Building Camp 3 - Oct 26th - Oct 30th Master Mind Camp Duration * Number of Kids * Price * $ Please enter the days you plan to attend * Add Another Event Remove Additional Event Total * $ Child Information Child Name * First Name Last Name * Last Name Grade * Date of Birth * Name of School * Parent/Guardian Information Parent/Guardian Name * First Name Last Name * Last Name Address * Address Street Address Street Address Street Address Line 2 Street Address Line 2 City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Phone * Email * Medical Information Physician Name First Name Last Name Last Name Physician Phone Medical Concerns Acknowledgement and Agreement For convenience and for the environment, Encinitas Karate utilizes on line forms for events and authorization. Please read the following section carefully. You will be asked for your authorization as your agreement to said policies. You will receive a copy of your agreement via email provided above. Invalid email or no authorization will result in a forfeited camp agreement and spots requested. Acknowledgement and Agreement Confirmation * I agree I don't agree and won't attent the event Late Pick Up Policy and Charges The first 10 minutes is no charge, after 10 minutes it is a $10 charge plus $1 a minute per child. Late Pick Up Policy and Charges Confirmation * I agree I don't agree and won't attent the event Reservations and Cancellation Policy Payment in full is required to reserve spot(s). A minimum of 8 attendees must be registered and paid in full for game night to occur. A full refund will be given in the event of Encinitas Karate cancels game night. You can cancel any game night up to 48 hours prior to game night, receiving a full refund. You can cancel a camp under 48 hours of the game, receiving a full credit for the game night to be applied to a future game night event. Reservations and Cancellation Policy Confirmation * I agree I don't agree and won't attent the event Authorization and Finalization I the designated parent or person having legal custody or guardianship of the minors shown above, or for myself, give permission for these minors to participate in all activities as described in the announcement for the program event. I hereby voluntarily and knowingly assume all risks and dangers inherent and incidental to the activities of the program. I will not hold the City of Encinitas, it's officers, agents, employees and volunteers as well as Encinitas Karate, its instructors, employees or other attending guests or parks visited liable for any injuries incurred during the program whether caused by equipment on or off site from building or the acts or omissions of others excepting, damage or injury soley caused by the willful misconduct of negligence of Encinitas Karate or its employees or agents. I the undersigned parent or person having legal custody or guardianship of the minors shown above acknowledge that there is no existing medical condition, food allergy and/or other condition of importance that is not listed above in section Other Info that will prohibit the mentioned minors above to participate in activities listed in the events announcement. I also acknowledge that all minors must be over the age of 5. I understand by signing below that I agree to the policies and have filled out this registration form accurately and to the best of my knowledge. Photography and/or Video Media will be utilized during the event and I acknowledge that Encinitas Karate has full rights and ownership to said media which will or can be used to market similar events for Encinitas Karate I waive the right to any compensation for pictures or videos taken and used by Encinitas Karate. I understand that Encinitas Karate can change activities, themes or guest speakers at any time and that Encinitas Karate is not responsible for Guest Speaker cancellations or agenda changes. Guardian's Electronic Signature and Authorization* Guardian agrees to abide by the policies set by Encinitas Karate Acknowledgement and Agreement * I agree to the terms and conditions listed on this website and will abide by them. No, I do not agree and will not attend reCAPTCHA Submit If you are human, leave this field blank.