Purple Dragon Mid-Term Camp Detailed Registration Form

Camper Information

Week Registering For

Camper's Name

First NameLast Name

Birth Date

MonthDayYear

Age

Gender

Address

Street Address

Street Address Line 2

Postal / Zip Code

Parent/Guardian Information

Name

First NameLast Name

Home Number

Format: (000) 000-0000.

Cell Number

Format: (000) 000-0000.

E-mail

example@example.com

Emergency Information

Secondary Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Format: (000) 000-0000.

Alt. Phone Number

Format: (000) 000-0000.

Does the camper have any allergies, chronic illness, or medical conditions?

If yes, please describe.

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Purple Dragon Cayman Islands during the selected camp. In exchange for the acceptance of said child’s candidacy by Purple Dragon Cayman Islands , I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Purple Dragon Cayman Islands and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against Purple Dragon Cayman Islands including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including karate. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Photo/Image Release Authorization I hereby authorize Purple Dragon to use, reproduce, and distribute my child's name, voice, likeness, photograph, and/or any other representation of my child, in connection with printed materials or other media it distributes, displays, transmits, or exhibits. Such distributions, transmissions or exhibits may include, but are not limited to, publications, newsletters, magazines, brochures, CD ROMs, websites and/or videos for internal or external purposes. I understand that my authorization grants Purple Dragon Martial Arts, Purple Dragon International Don Jitsu Ryu System®, and all other affiliated businesses of Professor Don Jacob and the Purple Dragon® system, the right to use, reproduce, and distribute my child's name, voice, likeness, photograph, and/ or any other representation of them without compensation or further notice.

Medical Release and Authorization As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the {Organization} . and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation I certify that I am 18 years of age or older, or the parent/ legal guardian of minor child listed below. I hereby release and discharge Purple Dragon International Don Jitsu Ryu System®, and all other affiliated businesses of Professor Don Jacob and the Purple Dragon® system for any and all liabilities arising out of or relating to the foregoing.

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

Purple Dragon Cayman Kids Mid-Term Camp Registration