CAMP REGISTRATION SHEET

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: _________________________________