2008 AKA Camp Registration Form

 

Campers Name:
Parent/ Gaurdian Name:
Home Phone:				Contact Number During Camp:
Address:
City :				:
State:		Zip:

Select Camp(s)
Date	Full Day	Half Day
June 30 - July 3
July 7 - 11
July 14 - 18
July 21 - 25

The following information is required under COMAR 10.16.06.27.
This information must be on file with AKA Karate Academy at the time of addmission to the camp.

Required Immunizations information: Day Camps:
 All campers must be current on all immunizations, unless they provide a written statement from either a licensed physician, indicating that the immunization is medically contradicted, or the parent/gaurdian indicating that they object to the immunization for religious reasons. Use the Maryland Department of Health and Mental Hygiene Immunization Certificate.

A. Date (Month and Year) of camper's last Tetanus (or DtaP) shot.
B. Is camper currently enrolled in Maryland school, private or public
            Yes. Name of School:
            No. Please furnish a record of immunization for diptheria, tetanus, pertussis, poliomyelitis, measles (ruboela), rubells (german measles),
                        and mumps
C. Is camper exempt from immunization on medical or religious grounds?
            Yes. Provide signed copy of Maryland Department of Health and Mental Hygiene Immunization Certificate. 
            No.

Health Information
Provide pertinent information on any health problems including; physical, psycharaitric, or behavioral problems.
Check any that apply, add additional comments in the section provided.

	Good General Health			Seizures
	Allergy (food or other)			Behavior Issues
	Diabetes			Learning Disability
	Asthma			Other Cronic Health Condition (explain below)

Comments

Please describe any medications that your camper is presently taking and note any medications they will require during camp

Terms and Conditions;
I, the undersigned, understand thet the Martial Arts, like any athletic activity, carries with it a risk of injury. I knowingly, willingly, and vouluntarily assume these risks. I agree not to hold The Anerican Karate Academy, Inc., its owners, instructors, employees, agents, or students liable for any personal or property injury, harm, or damage resulting from my participation ther in. I herby allow The Anerican Karate Academy, Inc. to use any photographs taken of the students for any promotional materials, advertisements, and web page for The American Karate Academy.
 
Electronic Signature:
 By typing your name and selecting I Agree below you are certifying that all the information contained in this documet to be true, that you are 18 years of age or older, and that you have read, and agree with the Terms and Conditions listed above.
 

Name:

Date:

 

I am 18 years old or over

I Agree