Request edit access
Spring Break Camp - 2017
Capoeira Spring Break Camp 2017 - Registration - Current Members / Returning Campers

Camp Dates: Monday March 20th – Friday March 24th
Camp Time: 9am – 4pm (7:30am – 6:30pm)
1. FREE early drop off starting at 7:30am
2. FREE lake pickup until 6:30pm

Each Day, Campers Must Bring:
o Lunch with two extra snacks
o Water bottle
o Capoeira uniform or camp shirt
o Change of clothing
o Spray Sunscreen (no lotion

Parent Full Name *
Your answer
Parent Phone *
Your answer
Parent Email *
Your answer
Child(ren) Name *
Your answer
Child(ren) Date Of Birth *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Number *
Your answer
Registration Options - Register by 2/10 and Save $10 off Weekly Rate! *
Weekly Rate: $135/wk or $40/day Half Days: $110/wk or $35/day (7:30am – 1:00pm) (1:00pm – 6:30pm) Fieldtrip: $12 ($10 sibling discount off full week rate)
Required
Payment Options *
Required
Additional Notes:
Please use this section for comments and questions. **Campers registering for select days instead of the full week please note the days below.
Your answer
Camp Information & Policies *
Payments: Full payment is due by Thursday, March 16th. If payment is not received by the start of business on Monday, a $15 late fee will be automatically applied. Please fill out the attached payment authorization form with your credit card information. Declined Payment: Declined payments will result in a $15 fee. There is a $30 fee for every returned check. Absence: Please contact us by 10am if your child will not be attending camp on a certain day.Refunds: There are no refunds or prorated credits for missed sessions due to sickness, vacation, or any other reason. The registration fee is non-refundable. If you withdraw from camp, and you have authorized us to charge your card for your payment, your money will be refunded in the following manner: Two weeks (or more) prior to beginning camp: 75% refund. One week prior to camp: 50% refund. No refunds will be granted once camp has started.Uniforms: Uniforms are required for all Capoeira classes. Students not wearing their full uniform may not be able to participate in class or other activities. While on fieldtrips, campers must be wearing their uniform shirt. **New campers are only required to wear their camp shirt for classesLunch & Snack: Please pack a healthy lunch and snacks (2) to send with your child each day. Student Pickup: A person that has been designated, as an “authorized person” on registration form, must sign out the student out each day.Pickup Time: Students may be picked up as late as 6:30pm at no additional cost. Students picked up later than 6:30pm will be charged $10 per 15 minutes late.Photo / Video: The parent/student understand and give permission to Capoeira Brazilian Pelourinho (referred to herein as CBP) to be photographed / video recorded and published or used in any lawful purpose. Capoeira Brazilian Pelourinho retains all rights of ownership to any video and photographs taken during classes, events, demonstrations, or any other activity in connection with Capoeira Brazilian Pelourinho. Personal Belongings: CBP employees & volunteers shall not be responsible for damaged, lost or stolen articles, inside or outside the facility.Discipline & Conduct: At all times, students must exhibit respect for themselves, respect for other students, respect for instructors, and respect for our facility. Parents are expected to support us in enforcing this policy.Please, no video games / electronics!
Required
Liability Waiver Release - Terms & Conditions *
In consideration of being permitted to participate in any way in a Capoeira Brazilian Pelourinho (CBP) / Capoeira for Tomorrow (CFT) programs as indicated below and/or being permitted to enter for any purpose any restricted area (here in defined as any area where in admittance to the general public is prohibited), the participant or the parent(s) and/or legal guardian(s) (if participant is a minor) named below agree: 1) I/We fully understand and acknowledge that:a. There are risks and dangers associated with participation in martial arts classes and other activities, which could result in bodily injury partial and/or total disability, paralysis and death. I /We RELEASE and hold harmless, Capoeira Brazilian Pelourinho officers, instructors and assistants from all liability for my personal safety.b. There may be other risks not known to us or are not reasonably foreseeable at this time.2) I/WE accept and assume such risks and responsibility for the losses and/or damages following such injury, disability, paralysis or death, however caused and whether caused in whole or in part by the negligence of the Releasees named below.3) I/We HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Capoeira Brazilian Pelourinho / Capoeira for Tomorrow, its owners, their directors, instructors, assistants, volunteers, the martial arts facility used by the participant, including it owners, managers, promoters, lessees of premises used to conduct the martial arts event or program, premises and event inspectors, underwriters, consultants and others who give recommendations, directions or instructions to engage in risk evaluation or loss control activities regarding the martial arts facility or events held at such facility and each of them, their directors, officers, agents, employees, all for the purpose herein referred to as “Releasee”. From all liability to the undersigned, my/our personal representatives, assigns, executors, heirs and next to kin For any and all claims, demands, losses or damages and any claims or demands therefore on account of any injury, including but not limited to the death of the participant or damage to property, arising out of or relating to the events(s) caused alleged to be caused in whole or in part by the negligence of the releasee or otherwise.4) I hereby give my consent to Capoeira Brazilian Pelourinho / Capoeira for Tomorrow, its instructors, employees, volunteers, or any emergency Personnel to administer necessary treatment to me or my child in the event of an emergency and to transport him/her by ambulance if the situation warrants. I assume all costs associated with any medical care, treatment, or transportation. 5) I/we assume all risks and hazards incident to such participation including transportation to and from the activity; and I/we do hereby waive, release, absolve, indemnify and agree to hold harmless Capoeira Brazilian Pelourinho / Capoeira for Tomorrow, the organizer, sponsors, supervisor, participants and person transporting myself and / or my child(ren) to and from activities, from any claim arising out of injury to myself or my child, whether the result of negligence or any other cause. I give permission for my child to attend trips provided by the CBP/ CFT with transportation provided through a third party or a CBP/ CFT vehicle.6) In the event of a serious accident or illness, I request that Capoeira Brazilian Pelourinho / Capoeira for Tomorrow contact me. If I cannot be reached, CBP / CFT may make whatever arrangements are necessary to provide emergency care and treatment for my child. This may include conveyance to treatment at a hospital or other medical facility. I will assume responsibility for payment for services rendered. In case of an accident or illness where immediate treatment of my child is not necessary, but where he/she is unable to remain at the CBP/CFT, I request that CBP/CFT attempt to contact me first at the numbers that I have provided to arrange transportation for my child. In the event that I cannot be reached, please contact the emergency contact I have listed.7) I, the enrollee or the member, irrevocably authorize Capoeira Brazilian Pelourinho / Capoeria for Tomorrow and those acting under it’s authority, to copy, use, publish, advertising, trade, or any other lawful purpose whatsoever, photographic portraits, pictures or videotapes of me, in which I may be included in whole or in part.I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT AND I FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms