Student Registration & Release Form
Personal Information
Email address *
Student Full Name *
Your answer
Date of Birth *
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Address || City || State || Zip *
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Parent contact 1 *
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Mobile Phone *
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Home Phone
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Email Address *
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Parent contact 2 *
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Mobile Phone *
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Home Phone
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Email Address
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Emergency Contact *
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Relationship to student
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Emergency Contact Phone *
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Emergency Contact Email *
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Please describe any medical conditions your student may have: *
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Please select all programs dates that you are looking to enroll your child:
Please select all weeks you are signing up for SUMMER CAMP 2018
Release form
I hereby release the WC Capoeira Kids Camp, Omulu Capoeira, B'Nai Shalom Preschool, The Contra Costa Jewish Day School and Capoeira Luanda, its staff and instructors from any and all claims for damages, injuries, theft or loss of property, which I may incur on any premises where I participated in capoeira kids class programming.

I ____________________________ as an individual or as a parent/guardian of the participant, ______________________________, named herein, understand and acknowledge that participation in WC Capoeira Kids Camp class at B'Nai Shalom Preschool, The Contra Costa Jewish Day School, Omulu Capoeira and Capoeira Luanda programs may expose me or the above named participant to activity-related risks and risk of accidental injury, damages or loss. I understand that although precautions are taken by WC Capoeira Kids Camp class, B'Nai Shalom Preschool, The Contra Costa Jewish Day School, Omulu Capoeira and Capoeira Luanda, I am or the above named participant is responsible for our own safety. I am aware that there are certain risks involved when I or the above named participant participate in WC Capoeira Kids Camp class, B'Nai Shalom Preschool, The Contra Costa Jewish Day School, Omolu Capoeira and Capoeira Luanda, programs and knowingly assume all risks and hereby collectively and individually release from responsibility and agree to indemnify and hold harmless the WC Capoeira Kids Camp class, B'Nai Shalom Preschool, The Contra Costa Jewish Day School, Omulu Capoeira and Capoeira Luanda, its officers, agents, board of directors, representatives, employees, independent contractors, volunteers and assigns from all rights, claims, demands, and injuries, including death, damages or loss of any kind, known and unknown, which I or the above participant may sustain as a result of participating in any and all activities connected with or associated with such WC Capoeira Kids Camp class, B'Nai Shalom Preschool, The Contra Costa Jewish Day School, Omulu Capoeira and Capoeira Luanda. I accept my responsibility that I and the above named participant have no physical or psychological condition that would prohibit me or the above named participant from participation in WC Capoeira Kids Camp class, B'Nai Shalom Preschool, The Contra Costa Jewish Day School, Omulu Capoeira and Capoeira Luanda. I hereby authorize the WC Capoeira Kids Camp class, B'Nai Shalom Preschool, The Contra Costa Jewish Day School, Omulu Capoeira and Capoeira Luanda, to act for me or the above named participant according to their best judgment in any emergency requiring medical attention. I do hereby release and grant permission for the WC Capoeira Kids Camp class, B'Nai Shalom Preschool, The Contra Costa Jewish Day School, Omulu Capoeira and Capoeira Luanda, to use any photos of me or the above named participant for promotion and advertisement purposes without remuneration. I have read and do fully understand all the above provisions.

Signature (typing your name below is electronic verification that you have read and agree with the waiver of liability as parent or guardian of your student) *
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Date *
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How did you hear about us?
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Are there any additional notes and anecdotes we should know about your student or family?
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For 20% off discount CAMP payment please pay $184.00 by clicking on the link : www.PayPal.Me/wckidscamp
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