QPJC KIDS JUDO CAMP 2018 REGISTRATION FORM Official use only Camp:_______________________________________ Horseback Riding:______________________________ Hiking:_______________________________________ Other:________________________________________ Please pay by cheque or cash to Mark Littrean OR Queen’s Park Judo Club

PLEASE STATE WHEN YOUR CHILD WILL BE ATTENDING:

MONDAY 16TH TO FRIDAY 20TH JULY OR

IF ATTENDING BY THE DAY OR PART OF THE DAY PLEASE TICK THE BOX(ES) BELOW:

Cost per child (not including hiking and horseback riding): $500 Or

$150 daily

CHILD’S INFO.

NAME : ______

ADDRESS : ______

DATE OF BIRTH : (must be born between 2004 and 2012)

GENDER : ; WEIGHT (optional) ; HEIGHT (optional): ______

ALLERGIES, ILLNESSES, DISABILITIES: ______

SPECIAL REQUESTS: _________________ ______ ______

YOU CAN SHARE WHAT IT IS YOU ARE LOOKING FOR YOUR CHILD TO GAIN FROM THIS CAMP (optional):________________

__________________________________________________________________________________________________

PARENT’S/GURDIAN’S INFO.

NAME: ; ADDRESS: ; RELATIONSHIP TO CHILD: ______

PHONE #1: ; PHONE #2: ; EMAIL: ______

ADDITIONAL CONTACT INFO. (Must be able to get to the dojo within 15 minutes if requested)

NAME: ; PHONE #1: ___; PHONE #2: ______

The Camp Director, his assistants and the external instructors undertake to exercise every precaution in the practice of all activities at this camp. In the full understanding that my child will be engaging in contact sports and other outdoor activities, and that there is the possibility of injury, I do not hold the Queen’s Park Judo Club, the Camp Director, his assistants and the external instructors liable for any injury caused to my dependant as a result of participation in this camp.

NAME OF PARENT/GUARDIAN SIGNATURE DATE

MON

16th

TUE

17th

WED

18th

THU

19th

FRI

20th