2006 New England Martial Arts Summer Camp
Make all checks or money orders payable to:
Raffi Derderian 1010 Plainfield St. Johnston, RI 02919
NAME_________________________________________________ TEL (____)_____________________________
ADDRESS_________________________________________ CITY___________________ STATE_____ ZIP_________
AGE___________________ EMAIL_______________________________________
SCHOOL_____________________________________ INSTRUCTOR________________________________________
SCHOOL ADDRESS________________________________________________________________________________
YOUR RANK_______________ HOW DID YOU HEAR ABOUT THIS CAMP?_______________________________
Print clearly, photocopy this form as needed.
Send separate registration form for each person.
Both Days
(if postmarked on or before June 17, 2006 - $105.00 _____After June 17th $125.00_____
One Day Only
(if postmarked on or before June 17, 2006 - $75.00 _____After June 17th $90.00_____
Please provide the following health related information
_____(Yes/No) Do you have any health related conditions that may affect your participation in this camp?
If yes please explain in detail:
Who should we notify in the event of any emergency?
Name_____________________________________________ Relationship_____________________________
Phone number____________________________________
IT IS MANDATORY THAT ALL PARTICIPANTS OR THEIR GUARDIANS SIGN THIS RELEASE FORM
In consideration for my acceptance at the New England Martial Arts Summer Camp held on June 24 -25, 2006, at Newman YMCA in Seekonk, I submit this application for attendance. I do hereby assume full responsibility for any and all damages, injuries, or losses that I may sustain, if any, while attending or participating in this event. I hereby waive any and all claims against Mr. Raffi Derderian Jr, Derderian Academy of Martial Arts, Newman YMCA and its entire staff, as well as anyone associated with the New England Martial Arts Summer Camp, for any injuries or damages that I or my child may sustain. I also affirm that I am not in possession of, nor will I use, any illegal drugs or other illegal substances while in attendance at this camp. I understand that I will be held financially responsible for any damages to any property I may be responsible for damaging. I also understand that there is a risk of physical injury with participating in martial arts events and I certify that I am in good physical condition and have no disabilities that might hamper my participation in the program. I also certify that I have medical insurance. I consent that any pictures furnished by me or taken of me in conjunction with this event can be used for publicity and I waive compensation for this. I agree to follow all of the rules that are established regarding my conduct during this event and understand that failure to do so will result in expulsion from this event without refund. I certify that all of the information on this registration form is correct and true.
NAME_____________________________________________________________________DATE_______________________
All participants must sign, parent or guardian must sign if participant is under 18