Online Registration Form | Budo Camp Online

Fields marked with a * are required

First Name *

Last Name *

Date of Birth [example: mm/dd/yyyy] *

Parent/Guardian First and Last Name (if attendee is 19 years of age or younger)

I am 19 years of age or younger.

Please note that if you check this box, a parent or guardian must give their permission for you to participate and sign your Release and Waiver of Liability Form prior to Budo Camp. Please bring the signed form to Budo Camp.

Phone Number [example:(555) 555-5555]

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Email Address *

Emergency Contact Name (first and last) *

Emergency Contact Relationship *

Emergency Contact Phone Number [example: (555) 555-5555] *

Martial Arts Experience *

Please list all prior training -- style, rank, time frame, instructor, organization. Put \"None\" if you have no prior experience.

Health Information *

Please list any health conditions or physical impairments you currently have, or have had in the past. Please also include any medications you are on, dosage times, amounts, and any requirements for the staff.

Notes:

Please type any additional notes you need to add regarding this registration form: i.e. information regarding payment, questions, or other items not listed.

Note: Budo Camp T-Shirts are free if registration is received before July 29th. T-Shirts will be $20 if registration is received by Sept. 2nd, and $25 if registration is received by Sept 20th.

Electronic Signature *

Typing your full name into the \"Electronic Signature\" box above validates that you have read and agree to the Release and Waiver of Liability and Assumption of Risk Agreement to Participate. The electronic signature is required for registration.

4 + 7 = *

Why the math question? It\'s because we hate spam as much as you do. Answering this question correctly will confirm that you are human, and not a robot. Thanks for participating.

Registration

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Budo Camp 2012

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