Summer Camp 2018 Registration Form

Camper Name:____________________          Black Tiger Karate Organization Camp Registration Form                         Age:______

By completing this form you acknowledge that you’re giving up certain legal rights and hereby represent and warrant to the Black Tiger Karate Organization  that you are over the age of majority, you are registering on behalf of a minor and are his/her parent/legal guardian and as such are fully authorized and entitled to enter into this agreement on his/her behalf. Please note all sections of this agreement must be completed. Payment is due in full upon registration by direct payment. The program fee is non-refundable.


Parent/Guardian -Main Contact Information

Parent/Guardian #1

First_______________________________________Last_________________________________  Gender: M_____F______

Street Address ________________________________________________________________________________________________

Town/City ____________________ Postal code  ________ Home Phone ________________ Work Phone _________________

Cell phone ______________________________ E-mail _________________________________


Secondary Contact/Alternate

First_______________________________________Last_______________________________ Gender: M_____F ______

Street Address_________________________________________________________________________________________________

Town/City ____________________ Postal code  ________ Home Phone ________________ Work Phone _______________

Cell phone ______________________________ E-mail _________________________________




Camper Information/Child

First _______________________________ Middle _________________ Last _______________________     Gender: Male __ Female__

Grade _______ Birth date _____/_____/______ Age (as of June 30, 2018) _____

Street Address _________________________________________________________________________________________________

Town/City ___________________________ Postal code ___________



Emergency Contact Information – Alternate Pickup/Release

Emergency Contact  This is a person over the age of 16 who is authorized to pickup your child and can be contacted by Black Tiger Karate Organization staff when the parent/guardian can’t be reached.

First Name ___________________ Last Name ___________________ Home Phone ________________ Work Phone ______________

Cell Phone ___________________ Email _____________________________________ Relation to child ______________________

Campers 11 years old and under must be signed in and signed out by a parent/guardian or a person over the age of 16.

If your child is 12 years old does she/he have your permission to be released on their own at the end of their camp day?


Yes __ No __                                                     Signature:__________________________________________


Code Of Conduct

The safety of each individual in the program is of the utmost importance to the Black Tiger Karate Organization. Each registrant must recognize a personal responsibility to learn and follow at all times the safety and other rules established by Black Tiger Karate Organization staff. I hereby agree that any behavior of the registrant that places him/herself or others at risk may result in the registrant’s immediate dismissal from the program. Further, if dismissed from the program, I agree to cover any expenses arising from such dismissal. I hereby acknowledge and agree that no refund will be granted for dismissal or removal of the registrant at his/her request before the end of the program session. In order to ensure the safety and well being of all the individuals participating in the program, the Black Tiger Karate Organization  reserves the right to alter the program at any time without notice or compensation to the Registrant.


I have read and understand the Code Of Conduct.  Signature:__________________________________________


Health History And Personal Information

The more information you can provide, the better we can meet the needs of your child. This information will be used by the camp director and staff to support your child. If there is additional information of a sensitive nature, please feel free to send a separate letter marked “confidential” to the attention of Camp Director. Whatever information you send us will be treated with confidence and respect.

Is the participant under any form of treatment for an illness, condition or injury?  Yes___   No ___

If yes, please explain and detail routines, medications, adaptations etc. We also need you to complete a Medication Dispensing Form.


Is your child allergic to any type of food or medication?

Yes__ No__ If yes, explain:______________________________________________________


I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the Black Tiger Karate Organization staff to secure the necessary medical services in the event my child is injured or becomes ill.

Parent’s/Guardian’s Initials ____________


I understand that the Black Tiger Karate Organization will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.


Parent’s/Guardian’s Initials ____________


Black Tiger Karate Organization Summer Camp TUITION INFORMATION –


Session 1 –  2 week camp from Tuesday July 3 – Friday July 13

Session 2 – 2 week camp from Monday July 16 – Friday July 27, 2018

Date Program





A.M, P.M.

Or Both




Total Session


*Jul 3-Jul13 270.00 15.00/Day before care

15.00/Day after care or

20.00/Day for both

Jul16 – Jul 27 300.00 15.00/Day before care

15.00/Day after care or

20.00/Day for both

Session 1 & 2 510.00 Extended Care as Above   Sub-total  

*Short Week – Closed Monday, July 2.

Note: Sibling Discount – $10.00 off per child per week. 1st Child pays full tuition rate. Discount for each additional child. Separate registration form required for each child.


Payment Method  Total Fees Due     $____________________________


_________Direct Payment to care of Paul Yanuziello – Camp Director

_________Cheque – Please make cheque payable to Paul Yanuziello – Camp Director – Black Tiger Karate

_________Online Credit Card through Paypal  – Mastercard or Visa


Terms of Agreement

Photo Release


I hereby give permission for my child to be photographed during the Black Tiger Karate Organization Camp. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet.  I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of Black Tiger Karate Organization Camp and its affiliates.


Parent’s/Guardian’s Initials ____________

Assumption Of Risk And Indemnifying Release

While Black Tiger Karate Organization Camp staff and instructors will make every reasonable effort to minimize exposure to known risks associated with each Registrants participation in the Summer Camp Program, I hereby acknowledge that I and/or my child if I am registering on his/her behalf may be required to participate in various physical activities that may involve risk of physical injury. In this regard, I agree that I have provided a complete an accurate health history and hereby  permit the Registrant to participate in the full range of Program activities, except as specifically noted by me in the health information section of the Program Registration. In consideration for the Registrants opportunity to participate in the Program, the receipt and sufficiency of which is hereby acknowledged, I hereby release and forever discharge the Black Tiger Karate Organization, its respective officers, directors, employees, volunteers and agents and their respective successors and assigns from any and all liability for damages sustained in consequence of loss, injury, or damage to the Registrant, and from all other actions, causes of action, claims, demands or damages of any kind with respect to death, injury, loss or damages to any person or property arising out of or connected with preparation for, or participation in, the Summer Camp Program.

__________Please Initial


Medical Emergencies

In case of an accident or an emergency, involving the Registrant, and immediate contact by Black Tiger Karate Organization with a designated contact cannot be made, I hereby authorize and grant permission to Black Tiger Karate Organization staff to secure proper medical treatment and authorize on the Registrants behalf all procedures without limitation. I agree not to hold the Black Tiger Karate Organization responsible for any costs or injury arising out of an emergency situation. __________Please Initial


Registration Agreement


By signing my name I or my legal guardian acknowledge that I or we have carefully read and understand the Assumption of Risk and Indemnifying Release Statement, and Medical Emergencies statement.  __________Please Initial


Date: __________________________


Camper Name: ______________________________________________________________


Guardian Signature: __________________________________________________________


Printed Name of Parent/Guardian: _______________________________________________



Black Tiger Karate Organization Summer Camp

2450 Finch Av. W. Unit 4

North York, On. M9M 2E9

Phone: (416)749-6183              E-Mail

Camp Director: Paul J. Yanuziello    Phone: (647)551-2249   E-Mail:


For Office Use Only:


Date Received:                                                     Date Processed:                                                                   Staff Initials:



Receipt Sent By:    E-Mail ___    Mail ___   Personally ___