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REGISTRATION FORM
Student Information
Student's First Name
Student's Last Name
Student's Age
Student's Birth Date
Would you like to add additional students?
*
Yes, add more students
No, enroll only one student
List all additional students, and their birth dates.
Street Address
City
State
Postal / Zip code
Guardian Information
Parent/ Guardian 1 Name
Parent/ Guardian 1 Email
Parent/ Guardian 1 Mobile #
Parent/ Guardian 1 Work #
Parent/ Guardian 2 Name
Parent/ Guardian 2 Email
Parent/ Guardian 2 Mobile #
Parent/ Guardian 2 Work #
Who else is authorized to pick up your child (aside from parents/guardians)?
Contact First Name
Contact Last Name
Contact Mobile #
Relationship to Student
Who should be contacted in case of an emergency (aside from parents/ guardians)?
Contact First Name
Contact Last Name
Contact Mobile #
Relationship to Student
Which sessions do you plan to enroll your student in?
Week 1: May 29 - June 2
Week 2: June 5 - June 9
Week 3: June 12 - June 16
Week 4: June 19 - June 23
Week 5: June 26 - June 30
Week 6: July 3 - July 7
Week 7: July 10 - July 14
Week 8: July 17 - July 21
Week 9: July 24 - July 28
Week 10: July 31 - August 4
I hereby certify that my child is in average health and capable of participating in theYusabu Taekwondo Camp.
*
Yes
No
Please list below any medical conditions that may affect your child while attending camp or participating in a field trip undertaken by Yusabu Taekwondo (Include allergies, if any).
Insurance Provider Name and Phone #
I consent to my child's participation in off-site field trips, and outlined activities.
*
Yes
No
I attest that I am the parent and/or legal guardian of the minor student being enrolled to attend Yusabu Taekwondo. I hereby release and forever discharge Yusabu Taekwondo School, their agents, and/or representatives from any and all liabilities arising from any and all injuries as a result of any accidents occurring during any and all field trips taken by the minor student named above.
*
Yes
No
By typing your full name below, you agree to these terms above.
Please confirm today's date.
Register
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