Mid-California Tae Kwon Do
BLACK BELT CAMP 2008
APPLICATION FOR PARTICIPATION 

Name: _______________________________  Age: _____  Rank: _______
Address: ________________________________ City: ________________   State: _________
Phone: ____________________ Emergency Contact: _________________________________
Pertinent medical information and allergies: _______________________________________
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Signing this application for participation in the 2008 Black Belt Camp in Modesto, California, allows the participant to be treated for medical emergencies, which may arise during the camp.  This emergency permission is for the period of July 8-12, 2008 and expires at the end of the Black Belt Camp schedule.

 I, the undersigned, do hereby voluntarily submit an application for attendance and participation in Mid-California Tae Kwon Do Black Belt Camp, and related activities. I hereby assume full responsibility for any or all damages, injuries, or losses that I may sustain or incur, if any, while attending or participating in activities related to Mid-California Tae Kwon Do. I waive all claims against sponsors and the staff of Mid-California Tae Kwon Do, individually or collectively.  I fully understand that any medical treatment given to me will be necessary and legal first aid only.

 A $50.00 non-refundable deposit is required by June 15, 2008.   The total cost of the camp is $125.00 and is due and the balance is due and payable on the first day of camp.

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Student Signature, or Parent/Legal Guardian                          Date