After School Martial Arts (Capoeira) - 2018 / 2019
Welcome and thank you for your interest in After School Capoeira Martial Arts. Our program is a great way for your child to release extra energy in a safe, fun, healthy, and constructive way. Children have fun learning the unique martial art of Capoeira while developing self-confidence and self-control all within a safe, positive, and nurturing environment.

We offer an exciting alternative to standard after-school care and we pride ourselves on providing a top quality program where your child will become more fit, focused, disciplined and self-confident! The children are immersed in a positive environment centered on all the benefits Capoeira has to offer:

Capoeira Activities:
• Capoeira movements & self-defense
• Anti-bullying & confidence building activities
• Acrobatics: floor and trampoline
• Capoeira Music: learn how to play three different instruments and songs in Portuguese
• Capoeira history & culture activities

After School Capoeira Includes:
o Transportation from school to the academy
o Supervised homework time & help
o Daily Capoeira class
o Extended pickup time until 6:30pm


How Do I Enroll?
1. Completely fill out this online registration form.
2. Save your child’s spot by paying the registration fee of $55, which includes your child’s martial arts uniform. A CBP staff member will contact you within 48 hours to confirm your registration and answer any questions you might have!

Email address *
Parent #1 - Full Name *
Your answer
Parent #1 - Phone *
Your answer
Parent #1 - Email *
Your answer
Parent #2 - Full Name
Your answer
Parent #2 - Phone
Your answer
Parent #2 - Email
Your answer
Parent Work Phone Number(s) / Additional Contact Number *
Your answer
Home Address *
Your answer
Child Name - #1 *
Your answer
Child Birthday - #1 *
MM
/
DD
/
YYYY
Child T-shirt Size - #1 *
Child Name - #2
Your answer
Child Birthday - #2
MM
/
DD
/
YYYY
Child T-shirt Size - #2
Child Name - #3
Your answer
Child Birthday - #3
MM
/
DD
/
YYYY
Child T-shirt Size - #3
Emergency Contact Name & Relationship *
Your answer
Emergency Contact Number *
Your answer
Typical Pickup time *
Your answer
Does your child(ren) have any allergies? If so, please explain. *
Your answer
Does your camper require an EpiPen? *
Please provide details about your camper's anaphylaxis, including the date and description of the reaction.
Your answer
Name(s) of all other person authorized to pickup your child (in addition to Parents & emergency contact) *
Your answer
School Name(s) *
Your answer
Grade & Teach Name *
Your answer
What Time is Your Child Released from School *
Your answer
What Date would you like your child to begin? *
I understand that pickup will begin on or after my listed start date once I have received a confirmation phone call with a CBP staff member.
Your answer
Additional Notes:
Please use this section for comments and questions.
Your answer
General Terms of Agreement *
This registration agreement is executed as of the date registration is submitted, by and between Capoeira Brazilian Pelourinho, Inc, hereinafter referred to as CBP / CBP Martial Arts Academy / CFT, and the Responsible Party/Buyer named as Parent #1 or Parent #2, who has caused his/her signature to be affixed hereto.
Required
Each Day, your child must bring the following items: *
1. Snack 2. Capoeira Uniform
Required
Information & Policies *
Payments: Payments are due on the Friday before services are rendered. If payment is not received by the close of business on the Monday or the first day of that week, a $15 late fee will be automatically applied. If payment information changes, you must notify and update information immediately to avoid any declined payment fee or late charge. There is a $30 fee for all returned check. Cancelation: This agreement may be canceled by submitting a written notice 15 days in advanced. ABSENTEEISM: Due to the fact that schools require us to follow a strict pickup schedule, a $15.00 fee per occurrence, will be assessed for a failure to inform us when we do not need to pick up your child at school. Finding out from the school where you child is takes time and makes us late to the next schools. Please call (407.226.3195) by 10:30am or TEXT (321-710-7136) that day or let us know further in advance when we will not be picking up your child at school. Thank you for your cooperation! Refunds: There are no refunds or prorated credits for missed sessions due to sickness, vacation, or any other reason. 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. After School Snack: Please pack a healthy snack 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 your child 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. Inclement Weather: On days public schools are closed due to inclement weather, we will be closed. If public schools closed mid-day, it is the parent’s responsibility to retrieve their children and care for them.Photo / Video: Parent/student understands and give permission to Capoeira Brazilian Pelourinho (CBP) & Capoeira for Tomorrow (CFT) to be photographed / video recorded and published or used in any lawful purpose. The business all rights of ownership to any video and photographs taken during classes, events, demonstrations, or any other activity in connection CBP & CFT. Part Time Program: If enrolled in the After School program part-time, please understand that your space is not guaranteed; only full time students are guaranteed a space in the program. If all spots are taken, you will be given preference and be offered a full time spot before a new enrollee is accepted. Holidays / School Closures: When school is closed for two or more days in a given week, the weekly fee will be $25 per every day school is open. Typically, during teacher workdays and certain holidays, CBP provides a day camp open to all students. Personal Belongings: CBP & CFT staff & volunteers shall not be responsible for damaged, lost or stolen articles, inside or outside the facility.Cell Phone: Students with cell phones are permitted to use their phone to call parents after school in the van. Once arrived at the academy, students will not be allowed to play with phones or other electronics. Please note: We abide by the ORANGE COUNTY PUBLIC SCHOOL calendar.
Required
Absentee Policy *
ABSENTEEISM: Due to the fact that schools require us to follow a strict pickup schedule, a $15.00 fee per occurrence, will be assessed for a failure to inform us when we do not need to pick up your child at school. Finding out from the school where you child is takes time and makes us late to the next schools. Please call (407.226.3195) or TEXT (321-710-7136) by 10:30am that day or let us know further in advance when we will not be picking up your child at school. Thank you for your cooperation!
Required
Recurring Payment Authorization *
I understand that I have not already Paid In Full for After School Capoeira, CBP will contact me to add a credit / debit / EFT (check account) information to process my recurring payment. Payments are processed the Friday before the upcoming week of school. I understand that I am giving CBP permission to debit my account for summer camp on or after the indicated dates. Please note that any late or declined payment fee may change the amount of your schedule payment. If payment information changes, please notify us and update information immediately to avoid any declined payment fee or late charges.
Required
Travel Waiver *
I authorized the participants stated on this registration form, participating in Capoeira Brazilian Pelourinho, Inc classes, after school program, camps, and/or other programs permission to travel to and from the Capoeira Brazilian Pelourinho and participate in the field trips planned during as part of Capoeira Brazilian Pelourinho activities. I understand that, by signing this WAIVER, I am giving my express consent and permission for employees or persons designated by Capoeira Brazilian Pelourinho to transport my child to and from Capoeira Brazilian Pelourinho events and trips in Capoeira Brazilian Pelourinho-owned vehicles, leased vehicles or private vehicles. I understand that transportation is being made available as a courtesy in order to ensure that my child has the opportunity to participate in the event. I further understand and agree, for my child, and myself that neither the Capoeira Brazilian Pelourinho nor any of their directors, officers, employees, agent or volunteers shall have any liability for any injury or damage to my child’s person or belongings, whether the result of negligence or any other cause, arising out of or relating to transportation of my child to or from events related to or sponsored by Capoeira Brazilian Pelourinho.
Required
Emergency Care Waiver *
I hereby give my consent to Capoeira Brazilian Pelourinho, Inc, its instructors, employees, volunteers, or any emergency medical personnel to administer necessary treatment to my child in the event of an emergency and to transport him/her by ambulance if the situation warrants.
Required
Liability Waiver *
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 understand that Capoeira Brazilian Pelourinho, Inc. is a Martial Arts school and not a daycare center in as such, their stock and trade is not supervision and care. The irintent is to teachMartial Arts physical and philosophical character building skills. I understand that Capoeira Brazilian Pelourinho, Inc and is a drop-in facility and that such, my child(ren) is/are free to come and go. If my child(ren) is/are to stayin the facility it is because of my direction and not Capoeira Brazilian Pelourinho, Inc. 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