KIME Karate Program

C. Waldo Scott Center is pleased to announce receipt of grant support from Sentara Healthcare for our upcoming KIME Karate Program beginning January 2023.

The prgoram provies an inclusive opportunity to promote physical and social-emotional wellness among youth living in the Southeast community of Newport News, VA 23607.

Grant funded by Sentara Healthcare

Thank you for your interest in the KIME Karate program. The C. Waldo Scott Center (Scott Center) has partnered with the Concern Citizens for Justice (CCJ) to offer this youth development experience. The CCJ has advocated for youth and justice within the Southeast community since 2018. The CCJ advocates are familiar with our community, its strengths, and challenges, which make them an ideal organization for partnership. The CCJ has six (6) trained Black belt instructors, each having over 10 years of experience in teaching martial arts.

The KIME Karate program addresses the need to engage youth in a non-traditional sports opportunity, which will enhance their physical and social-emotional development. The KIME program will teach participants self-defense skills, which will help to protect themselves when necessary. What makes the KIME program unique is the added component of providing youth participants with information and skill-building workshops, which will assist in supporting their social-emotional wellness and foster resiliency. KIME’s wellness workshops address the following areas: self-regulation (discipline/impulse control); problem-solving; anger management; bullying; mindfulness; conflict resolution; communication skills; and emotional awareness. As these competencies will assist youth with their karate development, they can be practiced in various areas of their development (i.e. home, school, and community).

A participant’s “promotional belt” will be earned by regularly attending instructional classes, which will help them to learn and develop their skills for self-defense, and attendance of at least 6 social-emotional wellness workshops. The requirements for the “promotional belt” help with the development of the WHOLE PERSON.

Youth living in the Southeast community of Newport News, Virginia (23607) may be eligible for a fee waiver, as we strive to facilitate an inclusive program. The program experience has received grant funding through the Sentara Healthcare system.

Complete Your Registration Below

Child's Name *

Fiscal Year

Date of Birth *

Permission to Participate in Scott Center Programs

I grant permission for my child to participate in the programs and services (including KIME) sponsored by the C. Waldo Scott Center for H.O.P.E., during its operational hours.

I understand that programs and services may include athletic/recreational activities, educational programs, field trips to off-site activities, which will include transportation, and special interest groups/activities. I further understand I will be responsible for my child’s transportation to and from the Center programs. I, for myself, my child, heir, executors, and administrators waive and release any and all rights and claims for damages I or my child have against the C. Waldo Scott Center for H.O.P.E., the City of Newport News, and affiliated agencies, its employees, volunteers, and agents from any and all actions, causes of actions, injuries, claims, demands, cost, loss of services, expenses, and compensation whatsoever, on account of or in any way growing out of such participation in programs and services.

Name of Parent/Guardian *

Parent/Guardian Signature *

My permission for participation is effective as of the date of submission of this form and will continue through the date specified below. This permission may be withdrawn at any time by submitting a written request for such.

End Date *

Media Release

My signature below, provides consent, as youth’s parent/guardian, to allow for my child to be photographed, recorded (visual/voice), or by other means inscribing, reporting, or using my child’s name for the purpose of publicity or research or any combination of these. When consent is given it shall be used in a manner that respects the dignity and confidentiality of the youth. I understand that the media images and voice recordings may be used by the Scott Center beyond the date of this form as a continued means to promote the Scott Center and/or programs/services.

I authorize for my child to be involved in the following media formats:

Photographing

Publicity (newspaper, magazine, radio)

Recording (video, audio, or combination)

Public Appearances/Speaking

Name of Parent/Guardian *

Parent/Guardian Signature *

Medical Information

Name of Child's Physician *

Physician Phone Number *

Date of last health examination/visit *

Were any medical problems noted? *

Yes

Please identify any medical/health problems your child may have that program sponsors/instructors may need to be aware of while your child is participating in the program (i.e. asthma/respiratory problems, seizures, etc.):

Please identify any restrictions that youth participant has concerning physical activities:

Is the youth member participant taking medications? If so, please list such:

Please identify the source of any allergic reactions for youth member:

Parental Permission for Emergency Treatment of Minor

The law requires that parental/guardian permission be obtained for medical procedures on minors. My signature below as the parent/guardian of this minor child, grants permission for my child to be treated by a health service provider or medical emergency personnel in the case of assessment, injury, and/or medical emergency. I understand that such consent is given so that medical treatment or treatment for injuries may be rendered in a timely way, in the best interest of my child. Such consent however, does not hold the Scott Center staff, volunteers, and its affiliates responsible for making medical decisions on behalf of my minor child. Information contained in this health information form may be disclosed to medical provider/emergency personnel for the sole purpose of providing the best medical treatment and care for my minor child.

Name of Parent/Guardian *

Signature of Parent/Guardian *