Camp SMART Registration

Emergency Authorization:

I give permission for the summer camp facility to obtain emergency medical treatment, including emergency transportation, for my child if I cannot be reached immediately. I agree to be responsible for any emergency medical expenses incurred. (If parent/guardian refuses to sign, instructions must be attached stating what procedure the facility is to follow in an emergency.)

Describe any special needs or instructions below:
I give permission for my child to participate in: (Click on Yes or No and upload your signature for each line)

Parent/Guardian Agreement

Deposits/Fees: A registration fee of $25 is required pe r child. This deposit/fee is non-refundable. There is a weekly fee of $50 per
child. Weekly fees must be paid on every Monday of that week. There will be an additional $15 charge for late fees daily. Cancellations of the camp must be received in writing, at least two (1) week prior to the cancellation, in order to avoid being charged the final balance amount.

Waiver/release: I hereby grant permission for my child listed on this registration form to participate in all camp activities with the
understanding that good safety practices and adequate supervision are provided by The Spot (No More Dirty, Inc.). If there are any
restrictions or limitations to your child participating in any activities, please inform the staff.

Non-Sufficient Funds: A $35 fee will be charged for any checks returned due to insufficient funds.

Withdrawals/Cancellations: Notification of cancellation must be received by the Director of the Spot in writing no later than two
weeks prior to the start of a camp session. The family is responsible for the entire tuition if Child withdraws less than two weeks prior to
the start of a camp session, arrives late in the session, or leaves early. Exceptions may be made; these must be in writing and signed by
both the adult responsible for payment and either the Office Manager or the Director of No More Dirty Camp.

Medical History: The State of Alabama requires that No More Dirty has a Medical History Form including either a record of immunizations or a letter specifying that the child is not immunized and the reason therefore signed by a parent/guardian for each participating child. Child will not be able to begin the camp without a complete medical history form completed and on file

Medical Authorization. I agree that Camp SMART and/or Mentoring Through Martial Arts Summer Camp Staff may authorize the physician of their choice to provide emergency treatment in the event that neither I nor our family physician can be contacted immediately. Camp SMART and/or Mentoring Through Martial Arts Summer Camp agree to provide transportation to an appropriate medical resource in the event of an emergency and will not administer any drug or medication without specific instructions from the physician. In the event of such accident or illness, all medical expenses incurred are my responsibility. I release Camp SMART and/or Mentoring Through Martial Arts Summer Camp, and all of its employees, officers, directors, servants, and agents from liability incurred as a result of any act they may perform on behalf of my child. *

I Agree

Delivery of Child. I agree that when delivering my child to the facility, I or the person I have authorized to drop off my child, will personally deliver my child to his/her teacher or the staff person in charge and sign your child in.. I further agree that when picking up my child, I or the person I have designated, will personally come into the facility and receive my child from his/her teacher or the staff person in charge and will sign out my child. At no time will I leave my child at the school without first making his/her presence known to the staff, nor will I take my child from the facility without notifying my child's teacher. I further agree that I or the person I have authorized to deliver and/or pick up my child will sign my child in/out on a daily basis. *

I Agree

Child Abuse/Neglect. As a summer camp provider, Camp SMART and/or Mentoring Through Martial Arts Summer Camp is mandated by state law to report any cases where there is reasonable cause to believe that a child has been neglected, exploited, deprived, sexually assaulted, sexually exploited, physically injured or suffered death by other than an accidental means by a parent, guardian or caretaker, to the proper authorities. No More Dirty Summer Camp staff will cooperate fully with the authorities in the investigation of all such cases. To avoid any misunderstandings, parents are encouraged to keep the camp director aware of any unusual bruises, marks or injuries occurring at home *

I Agree

Confidentiality Statement. Information pertaining to your child is considered confidential and will not be released by Camp SMART and/or Mentoring Through Martial Arts Summer Camp to third parties without first obtaining your written permission. However, it may be necessary to share relevant information relating to your child's family situation, medical status and behavioral characteristics with authorized members of the state licensing agency or with persons authorized by the state licensing regulations or law to receive such information. *

I Agree

Person Responsible for Payment

Fill in the following information only if not already given on the top portion of this form:

Deposit and Payment Information

A $25 deposit is required with the registration form. Deposits are non-refundable. Weekly balances are due on the Friday by 5pm prior to the start of the next week your student attends Camp SMART. Cancellations or changes must be submitted in writing and received two weeks prior to the cancelled in order to avoid being charged the final balance amount. Changes are contingent on space being available.

Make cashier check or money order payable to: No More Dirty, Inc.
Mail application with payment to: The Spot, 5045 Memorial Pkwy., NW, Suite B, Huntsville, Alabama 35810

Camp SMART Registration

No More Dirty

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