Clone of RLMA - Spring Break Camp

Parent/Guardian Name*

First NameLast Name

Child's Name*

First NameLast Name

Emergency Contact*

E-mail*

example@example.com

Allergies / Medical Information

Authorized Pick Up List

Payment*

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer

By signing below I agree to all terms and conditions as outlined on this registration form and as stated at raiseleaders.org/terms. Medical Treatment: I hereby give permission for my child to be given CPR and first aid treatment by a qualified staff member of the RLMA, LLC (Raise Leaders Martial Arts) staff. In the event I cannot be contacted, I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I further consent to the disclosure of health information and to the medical, surgical and hospital care treatment and procedures to be performed for my child by a licensed physician or hospital selected by the RLMA, LLC (Raise Leaders Martial Arts) director when deemed immediately necessary or advisable by the physician to safeguard my child’s health. Insurance: I understand it is my responsibility to provide for my child’s accident and health coverage while participating in these programs and I further understand that RLMA, LLC does not provide this coverage. Payment and Refunds: I acknowledge that there is limited space in camp due to safety precautions and special restrictions regarding the COVID-19 pandemic and therefore my reserved space is non-refundable. Payment: I agree to pay my camp fees before the first day of camp attending based on the terms of this agreement. I authorize RLMA LLC to charge my card via Intuit Quickbooks credit card processing and Square payment services. I understand that it is my responsibility to bring any billing discrepancies to RLMA, LLC (Raise Leaders Martial Arts) attention within 60 days after they first appear on my financial statements. After 60 days, I waive my right to dispute such discrepancies. Participation: I give permission for my child to participate in all activities and classes at RLMA, LLC (Raise Leaders Martial Arts). I give permission for my child to be transported to and from said activities. This form is valid for Camp, January 1st 2025-January 2027. Release from Liability and Indemnification: Recognizing that RLMA, LLC (Raise Leaders Martial Arts) will do its best to ensure a safe experience, I understand that accidents may occur from my child’s participation in program activities. I agree to assume these risks. By signing below, I release RLMA, LLC (Raise Leaders Martial Arts), its owners, officers, employees, volunteers, independent contractors, directors and agents from all liability based on any damage, loss, injury or death whether it is the result of ordinary negligence or otherwise, caused to my child or to me from participation in RLMA, LLC (Raise Leaders Martial Arts) programs. I further agree to indemnify and hold RLMA, LLC (Raise Leaders Martial Arts) harmless from all claims that are in any way connected with my child’s participation in this program. Photography, Videography and Social Media: Permission is given to RLMA, LLC to use photographs and videos of myself/child (regarding martial arts and RLMA, LLC programs and activities) in promotional material.*

Please list any medical conditions or medications:

I have read and understand the above and have completed this form to the best of my ability.*