Boy's And Girl's Club Enrollment

Boys & Girls Club Karate Program – Intake & Waiver Required

Please complete the attached intake and waiver form accurately and completely, as it is required for enrollment in the Boys & Girls Club Karate Program. Do not skip any questions. If you have any concerns or questions, please contact us at 760-815-1254.

Program Details

This is a FREE program taught by internationally certified instructors.
All students will progress through the traditional colored belt system.
A karate uniform (gi) is NOT mandatory, however it greatly increases motivation and a sense of achievement. Uniforms are available for purchase for $40. → To order a uniform, please call or text 760-815-1254.

Open to all Boys & Girls Club members When: Every Wednesday at 5:00 PM Where: Boys & Girls Club of Vista 410 W California Ave, Vista, CA 92083

We look forward to seeing your child on the mat!

Questions? Call or text: 760-815-1254

Want a Karate Uniform Right Away? If you’d like to purchase the uniform quicker, you can buy and pick it up the same day at our main location (just down the road from the club).

Purchase Location: 1234 N Santa Fe Ave Vista, CA 92083

Price: $40 (cash or card accepted) Phone: 760-815-1254 (please call or text ahead so we can have it ready for you)

FREE PROGRAM

Date required

NAME (FIRST AND LAST) BGCV CHILD 1

GRADE CHILD# 1

Hight 1

NAME (FIRST AND LAST) CHILD 2

GRADE CHILD # 2

Hight 2

NAME (FIRST AND LAST) CHILD 3

GRADE CHILD #3

Hight 3

PARENTS (FIRST AND LAST NAME)

Cell Phone

ANY DISSABILITIES OR MESSAGES FOR SENSEI SAL

Street Address

City

Region/State/Province

Postal / Zip code

I accept terms & conditions (Hold Harmless Agreement I, the undersigned parent/guardian having legal custody/guardianship of the above said minor(s), give permission for the minor(s) to participate in all Cirincione’s Inc./Karate Kids in America/Shorinkan San Diego club programs and any other affiliations. The Minor/Adult is physically able and mentally prepared to participate in all activities as described in the announcement for the program. In consideration of said Minor/Adult being permitted in any Cirincione's Inc./Karate Kids in America/Shorinkan San Diego activity for observation, use of facilities and/or equipment, or participation of the above in any program. I, on behalf of myself (as parent, guardian, coach, aide, spectator, or participant) hereby acknowledge that :(i) I have read this document, (ii) I have inspected the facilities and equipment, (iii) I accept them as being safe and reasonably suited for the purpose intended and (iv) I voluntarily sign this document. I release Cirincione’s Inc./Karate Kids in America/Shorinkan San Diego and/or its directors, officers, employees, volunteers and any affiliates (collectively “Cirincione's Inc.”) from all liability to me for any loss or damage to property, inju ry, or death to person, whether caused by Cirincione's Inc. or otherwise and while such minor/adult is in or near any Cirincione’s Inc./Karate Kids in America/Shorinkan San Diego activity or branch. I agree not to sue Cirincione’s Inc. for any loss, damage, injury, or death described above and I will indemnify and hold harmless Cirincione’s Inc. and each affiliate from any loss, liability, damage or cost they may incur due to said minor’s/adult presence in, upon or near any Cirincione’s Inc./Karate Kids in America/Shorinkan San Diego clubs activity or branch; whether caused by the negligence of Cirincione’s Inc. or otherwise. I assume full responsibility for and risk of, bodily injury, death or property damage due to the negligence of Cirincione’s Inc. or otherwise. I do hereby authorize Cirincione's Inc./Karate Kids in America/Shorinkan San Diego clubs as agent for the undersigned, to consent with respect to said minor, to any x-ray examination, anesthetic, medical, dental, surgical procedure, unspecified medical treatment, and/or hospital care which is deemed advisable. The medical care is to be rendered under general or special supervision of, any physician and/or surgeon licensed under the provisions of the California Medical Practice Act. I understand that Cirincione’s Inc./Karate Kids in America/Shorinkan San Diego club programs and any other affiliate is not responsible for cost incurred for medical, surgical or dental care. I intend this document to be as broad and inclusive as is permitted by the laws of the State of California: if any portion hereof is held invalid, I agree the Release Form shall continue in full force and remain effective)

PLEASE CHECK YES IF YOU WANT TO BUY A UNIFORM FOR $40. SENSEI WILL SEND YOU AN INVOICE. MAKE SURE THE HIGHTH OF YOUR CHILD IS CORRECT. Click no if you will be purchasing one at the main site. Required

YES

Cell Phone