CHAMPION TAEKWONDO CENTER
INC.
Summer
Camp
Registration Form
June 23-27, 2008
Student’s Name: ________________________________ Age: ________
Address:
_________________________________Phone #: ____________
List
any allergies (including food allergies): __________________________
List
any medications the child is taking: _____________________________
Times
medications are taken: _____________________________________
Parent/Guardian
Names: ________________________________________
Parent/Guardian
Address: _______________________________________
E-mail: ____________________________________________________
Home
phone #: _________________ Work Phone #: _________________
Cell
Phone #: _________________ Other Phone #: __________________
In
case of an emergency contact (name): ___________________________
Their phone # and address:
_____________________________________
Child’s
Physician Name: _____________________ Phone #: ___________
Name
of Health Insurance: ______________________________________
Describe
any special medical considerations: _________________________
Hospital
Preference (phone & address): __________________________
_____________________________________________________________
Any
other information we should know about your child:_______________
_____________________________________________________________
_____________________________________________________________
Summer
Camp Fees ($75 + $5.15 tax) per week: _____________________
If we do not have at least 20 campers per week, we will cancel that week.
Make
payment to
Champion
Taekwondo Center
.
