NCMA Summer Camp Registration Form

1. PERSONAL INFORMATION: Please fill out completely – one form per child. Camper’s Name:___________________________________________________________________Age:___________ Address:________________________________________________City:_________________Zip:________________ Home Phone:______________________Cell:________________________Email:_____________________________ Physician:______________________________________________Phone:___________________________________ Emergency Contact:___________________________________________Phone:______________________________ Special Needs (Allergies, Medications, Etc.):___________________________________________________________ SESSIONS(Check all that Apply): PAYMENT INFO: Full payment is due at the time of registration ( ) Cash ( ) Visa ( ) MasterCard ( ) Check – Made out to North County Martial Arts Name on Card:________________________________________ CC#:________________________________________________ Exp Date:__________________ V-Code(3 numbers)_________ Signature:____________________________________________ I agree to have North County Martial Arts charge my credit card. NCMA Summer Camp Registration Form NCMA T-SHIRT $15- Required for Field Trips Select size (Circle One): Y = Youth Sizes; A = Adult Sizes YS YM YL AS AM AL AXL Number of shirts: _____X $15=$________total cost for shirts Permission Form and Medical Emergency Authorization: I / We the undersigned hereby waive, release North County Martial Arts and its staff from all rights and claims for damages, injury or loss to person or property which may be sustained or occur during participating in camp activities or while at camp, whether or not damages, injury, or loss is due to negligence. In the event that reasonable attempts to contact me at the phone numbers listed above have been unsuccessful, I hereby give my consent for the camp director to secure medical treatment opinions of two physicians concurring in the necessity for medical treatment and are obtained prior to the performance of such treatment: Signed:_______________________________________________________________ Date:_____________________ (Parent or Legal Guardian)