EnteSummer Camp Dates:


Parent/Guardian Name:


Child's Name: ____________________________________________________

Date of Birth: ________________ Cost per Camp: _____________ Date: _________

Total Balance Due: _________

Full Payment must be made before the beginning Summer Camp date. Two (2) days participation constitutes one camp. No refunds will be given. However, if a participant attends less than two days, a credit may be given for a following/future held Camp.

Parent/Guardian Signature:

_____________________________________ Date: ___________

Consent for Emergency Medical Treatment

As the parent or authorized representative, I hereby give consent to the Napa Tae Kwon Do Academy to obtain all emergency medical or dental care prescribed by a duly licensed physician (M.D.) osteopath (D.O.) or dentist (D.D.S.) for


(child's name). This care may be given under whatever conditions are necessary to preserve the life, limb or well being of the child named above.

Primary Physician's Name: _______________________________

Medical Record Number: _____________

Child has the following medication allergies:



Parent or Authorized Representative Signature:

____________________________________ Date: ____________

Home Address:


Home Phone: _________________________________

Work Phone: _________________________________