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CAMPER __________________________, _____________________ ________ _______________ Last Name First Name Age RANK Spring 2015 Taekwondo Camp Application and Information
AN INTRODUCTION TO CAM P REGION 102 SPRING TAEKW ONDO TRAINING CAM P
Welcome to spring 2015 Taekwondo Training Camp. We offer a unique weekend camp experience to ATA families called FUN
Camp. If you are looking for a camp for your kids, not all overnight camps are the same. We offer the traditional camp experience,
with Martial arts skills and values that will last a lifetime. ATA Camp is for all ranks and ages 9 years old through Adult, Rank
Camo Belt and above. (We do make exceptions for younger and lower rank students. Please contact us to find out if this would
apply)
The goal of our weekend camp is to be a resource for your child’s physical, mental and social development, while providing plenty
of fun. Campers have the opportunity to have fun while learning new skills and improving existing abilities with an emphasis on
sportsmanship, as well as technique. Our staff spends hours putting together a fun filled themed camp. We have had themes from,
CIA, Star Wars, to Songahm Strong (including nerf gun fighting). Campers develop their performance and presentation skills by
developing skits and demos that are performed for the entire camp. The camp is a two nights, three day packed with non-stop
Taekwondo Fun. Typically it is scheduled in May at Camp Manitoqua in Frankfort, IL. We have programs for teens that offer the
opportunity to grow by participating in leadership roles during leadership training and being a part of the crew and squad leaders.
Our older campers learn valuable leadership skills and are positive role models for the other campers. You can find details about
camp dates and pricing on our website. In addition, we have included general information, photographs and videos of our camp to
help you learn more about the best Taekwondo camp available. If you have any questions please email us at
[email protected]
Come see why kids come back year after year for….
W HO?
This camp is open to ATA students Camo through All ranks of Black Belt (with some exceptions)
AGE?
9 years old* through Adult *(a younger student or lower rank may be allowed to attend if their instructor is attending the entire
camp, and agrees to assume responsibility. The Instructor must call Sr. Master Barnum or Master Shoup to discuss the situation)
W HAT?
Train with ATA Masters! Train with a variety of Masters from Region 102. Mr. Wade, head of the Kids Fun
Camp has an eventful weekend of activities planned around a theme. This Taekwondo experience should not be
Missed. Learn advanced techniques for improving all aspects of your Taekwondo skills. Meet new friends,
Improve your competition skills, Develop team-building skills; improve your sparring skills, Learn leadership
Skills, Gain the competitive edge, and have FUN!
W HEN?
On Friday, May 15 th – Sunday, May 17 th 2015
W HERE?
Camp Manitoqua
8122 West Sauk Trail
Frankfort, IL 60423
FEE?
$210. Includes instruction, Lodging, Meals, and One T-Shirt (this shirt is to be warn the entire camp)
Please note: Additional T-shirts are available to pre Order at a discount rate of $12.00 a piece. If you register after 4/1 please speak
With Sr. Master Barnum to make sure it is not too late to order another Shirt
Deposit: $100.00 due by 4/1 to reserve Space (space is limited)
Late Registration Fee: $25.00 added if registering after 4/1
Make Checks payable to “ATA”
1 CAMPER __________________________, _____________________ ________ _______________ Last Name First Name Age RANK ATA Taekwondo CAMP DETAILS
CHECK IN:
Friday May 15 th , 2015 from 4:00-5:50pm
All Campers will report for training at 6:00pm ( First line-up: 6:00pm (Line up in workout clothes)
CHECK OUT:
Sunday, May 17th between 11:30-12noon
ITEMS TO BRING:
Your Taekwondo Belt
Workout clothes (including t-shirts, sweat pants, sweat shirts)
Sparring Gear (including head, hand, food, chest, mouth guards, and protective cup for males)
Protech Weapons (Ssang Jeol Bon, Bahng Mahng EE, Combat Bahng Mahngee (We will have a few
For sale on hand, Combat Bahng Mahngee is highly recommended but if you do not have one we will
Have alternative)
Athletic Shoes
Pillow, Sleeping bag, Towel
Toiletries, Sunscreen lotion, Bug Spray, Jacket
TO REGISTER:
1. Completely fill out the application found on the following pages and forward to Camp Coordinator Sr.
Master Barnum either Fax to: (630) 271-1219. Or mail to Karate for Kids, 12156 Oak Tree Lane,
Lemont, IL 60439
2. Contact Karate for Kids to confirm Application has been received. Call (630) 271-1200 or Email
Master Shoup at [email protected]
2 CAMPER __________________________, _____________________ ________ _______________ Last Name First Name Age RANK FOR OFFICE USE ONLY
Date rec’d ________________ Approved _____________ Confirmation Sent _____________
Amt. fee rec’d _____________ Date rec’d _____________ Paid by _____________
2015 SPRING CAMP APPLICATION
MUST BE FULLY COMPLETED BEFORE CAMPER IS CONFIRMED.
Mail to: Karate for Kids Attn: Sr. Master Barnum, 12156 Oak Tree Lane, Lemont, IL 60439 • (630) 271-1200 •
Fax: (630) 271-­‐1219 (please call before sending to ensure fax is turned on) Email: [email protected] • www.ATACAMP.weebly.com
ATA#: _______________________ Exp. Date: ____________ Gender: Male or Female
Full Name: ________________________________________ Rank: __________ Age: ________
Birthday: ____________ Email Address (required): ______________________________________
Address: _________________________________________________________________________
City: ___________________________________ State: __________ Zip: ______________
Home telephone: _________________________ Cell: ___________________________________
Instructor’s name: _________________________ School Location: ________________________ER Name: _________________________________ Relationship to Camper: ______________________
Phone Number: (Day): ___________________________ (Evening): _______________________
________________________________________________________________________________ If Minor: Father’s name: ____________________________________ cell: _________________
Mother’s name: ___________________________________ cell: _________________
T-­‐Shirt Size (circle one) one t-­‐shirt is included in campers fee CHILDREN’S SIZES: 6/8 10/12 14/16 ADULT SIZES: Small Med. Large X-large 2xl 3xl Yes,
I would like an additional T-Shirt at a lowered cost of $12.00.
Campers Name: _____________________________________ Size: __________________
*Please note that you must contact Sr. Master Barnum after 4/1 to insure its not too late to get an extra t-­‐shirt (630) 271-­‐1200. * Extra t-­‐shirt money must be turned in with deposit. Camper fee is
$210.00 for the weekend (please add $25.00 late fee if registering after 4/1) Registration fee, which must accompany application with the balance to be received before camp
Begins on May 15th at 6pm Camp fee includes food, lodging, t-shirt, and instruction ($210.00) $___________
Late fee if after 4/1 ($25.00) $___________
Extra T-shirt ($12.00) $___________
Total $___________
Minimum deposit ($100.00) $___________ Due at Camp $___________
Payment Choice:
Check __________ Credit Card: __________ CC: Visa MasterCard Discover Name on Card: _________________________________________ Card #:_______________________________________________ Exp. Date: _________________ Amount Auth: $________________ Billing Address( if different from above) Address, City, St., Zip __________________________________________________________ 3 CAMPER __________________________, _____________________ ________ _______________ Last Name First Name Age RANK To be completed and returned with application. * * * * * Application will NOT be processed without this form. * * * * *
CAMPER/FAMILY AGREEMENT: I, _________________________ want to attend ATA Regional Taekwondo Camp this year and:
(Print your full name) Place a check mark next to the following statements indicating you have read and understand each. _____ Understand the volunteer staff will do their best to help me and the other children have a happy, fun, safe and
Positive experience;
______Understand that volunteer staff and ATA/ Karate for Kids are not responsible for lost, stolen or damaged items
that I bring to the camp. We highly recommend that you make sure all Sparring Gear, Weapons, Bags, and Uniforms
have your name printed clearly and visible.
_______Understand that ATA has a policy that if, despite the efforts of the staff, I continue to display behavior that is
disruptive, disrespectful and/or dangerous, that it may be necessary to send me home. I also understand that such
negative behavior may result in my not being able to attend future camps;
_______Understand that ATA maintains a Zero Tolerance Policy with regard to alcohol, recreational drugs, weapons,
sexual harassment, and any behavior that threatens or endangers others. I also understand that any violation of this
Policy will result in my immediate dismissal;
_______Agree that I will sincerely try to participate in the activities to the best of my ability;
_______Agree that I will treat the other children and the staff with courtesy and respect;
Date: _________________
I hereby give consent for _____________________________________ to attend REGION 102w SPRING CAM P.
Name of applicant
In consideration for the acceptance of the applicant, we hereby release any claim or cause of action which may occur against Region
102w, American Taekwondo Foundation, the ATA camp employee/volunteer’s of either one and any other person acting with the
permission of either, arising out of any injury to his/her person of property during his/her stay at the Camp, in transit to and from
said Camp, or during any activity approved by any of said persons, and we agree to assume any claim which said child in his/her
personal capacity might have against any of said persons for injury as herein stated. As a contribution to ATA fun camp valuable
consideration, permission is hereby granted to the ATA or Region 102w Camp, to use any photograph(s) of
(Name of Applicant) ________________________________ for advertising of camp and in any and all publications and other
types of news media without limitations or reservations.
Parent/Legal Guardian: _____________________________________________________________________
Address/City/State/Zip: _____________________________________________________________________
Phone Numbers: Home (______) ___________________ Work (______) ________________________
This application has been filled out by: (Please Print)
Name ____________________________________________ Title_______________________________________________
Address _____________________________________________________ Daytime Phone ____________________________
Campers Signature: _____________________________________________Date: _____________________ Parents Signature: _______________________________________________Date: ______________________ 4 CAMPER __________________________, _____________________ ________ _______________ Last Name First Name Age RANK PERSONAL HEALTH AND MEDICAL SUMMARY Name: __________________________________________ Date of Birth ____/____/____Age ____Sex ____
Parent or Guardian Ph.( _____) _______- ____________
Address City State
__________________________________________________________________________
Alternate Person to Notify Relationship Ph.(_____ ) ________-______________
Name of personal physician: _______________________________ Ph.(_____ ) _________-___________
Insurance Carrier _________________________________ Policy# _____________________
MEDICAL INFORMATION PAST AND PRESENT Known Health problems: Asthma _______, Heart Disease _______Allergies _______, Convulsions _______,
Diabetes _______, Hemophilia _______, High Blood Pressure _______, Other _______
Explanation for above:____________________________________________________________________________________________ Allergies:
Food______, Plants______, Poison Ivy ______, Medicines ______, Insect Bites ______, Other _______
Explanation for above Any reason to restrict full activity including, long hikes, strenuous activities? - Yes ___ No _
List any conditions limiting full participation. (Physical or emotional)
_____________________________________________________________________________________
Any reasons for medicines to be taken at camp? -­‐ Yes _ No _ if so, list medicines, and send ample supplies
and directions for use __________________________________________________________________
_____________________________________________________________________________________
Are camper’s shots up to date? Yes / No (ALL CAMPERS ARE REQUIRED TO HAVE HAD THE MEASLES VACINATION) NOTE: Please provide insurance form and or card from your insurance company. The hospital requires insurance information.
MEDICAL RELEASE: In case of Illness or injury, ATA faculty has my permission to procure medical treatment for the below named
minor. LIABILITY RELEASE: The undersigned, for himself or herself and personal representatives, assigned. Heirs and next of kin
(herein referred to as releasers), hereby releases, waives, discharges and covenants not to sue region 102W, ATA, S, its agents,
servants and teachers (herein referred to as releases) from all liability to the releasers for all loss or damage and any claim or
demands on account of injury to the person or property or resulting death of the releasers, whether caused by the negligence of
releases or otherwise while participating in activities associated with summer camp. The undersigned is fully aware of the inherent
hazards and hereby elects to participate voluntarily and assume all risks of loss, damage or injury that may be sustained by camper
named:
______Tylenol, _______aspirin, and ________antihistamines release: (If acceptable, check and initial) __________
The undersigned has read and voluntarily signs this medical release and waiver of all liability and assumption of risk
agreement.
Releaser signature: ________________________________________________________ Date: _______________________________ ALL CAMPERS MUST HAVE THIS INFORMATION ON FILE DURING THE WEEK OF CAMP 5 CAMPER __________________________, _____________________ ________ _______________ Last Name First Name Age RANK DID YOU REMEMBER TO? o Include your $100.00 Deposit or Credit Card Information for deposit?
o Complete and sign your medical information?
o Sign Family/Camper Agreement?
o COMPLETE PAGES 3-6?
o Mail or Fax all completed paperwork?
Mail to: Karate for Kids
12156 Oak Tree Lane
Lemont, IL 60439
Fax to: Attn: Sr. Master Barnum
(630) 271-1219
Please contact (630) 271-1200 to confirm fax went through
Check Website for Tips, Information, and additional Packing Tips 6