Region 22 One-Day Dan Camp registration form

We are excited to offer this year’s Black Belt Camp for both youth and adult students! The camp gives students the opportunity to strengthen their skills, build friendships, and continue growing as martial artists.

For: Adult & Youth Red Belts and Above

Cost: $65 (Camp T-shirt included)

Date: Saturday, August 8, 2026

Check In: 8:30am-9am

Training Time: 9am-4pm

Check Out: 4pm-4:30pm

Location: Kerr Fitness Center at La Roche University

Address: 9000 Babcock Blvd, Pittsburgh, PA

Choose your role:

PARTICIPANT Name

First NameLast Name

Date of Birth

Date

Age at registration

Age at event

EVENT Date

Date

Your WTSDA school / Studio

Must have permission of your regional director and instructor if you are not from Region 22

School if other

Gup or Dan Number

Your WTSDA rank (on day of clinic)

Email for confirmation and updates

example@example.com

Gender

Parent/Emergency contact Name #1

First NameLast Name

Parent/Emergency Contact Phone Number #1

Area CodePhone Number

Parent/Emergency Contact #1 email address

example@example.com

Parent/Emergency contact Name #2

First NameLast Name

Parent/Emergency Contact Phone Number #2

Area CodePhone Number

MEDICAL

Please explain any medical conditions or special needs (or enter "none"):

CAMP T-SHIRT

Select T-Shirt Size

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Signature of participant (over 18 years of age)

Signature of parent/guardian 1 ( if participant is a minor)

Are you a resident of the US Commonwealth of Pennsylvania?

Do you have sole legal custody of the participant?

Is the legal guardian # 2 available for signature?

If the other guardian is not available would you like to have the form sent to them for signature?

ACKNOWLEDGEMENT:

Parent/Guardian #2 email

example@example.com

Signature of parent/guardian #2

My Products

2026 DAN CAMP$65.00

Youth and Adult camp

Enter coupon

Total $0.00

Credit Card

Date