2016 ATA Region 108 Black Belt Camp Open to Black Belts 8 and older YMCA Camp High Harbour, Lake Allatoona September 23rd, 24th and 25th

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1 2016 ATA Region 108 Black Belt Camp Open to Black Belts 8 and older YMCA Camp High Harbour, Lake Allatoona September 23rd, 24th and 25th FULL NAME ATA NUMBER RANK ADDRESS CITY, STATE, ZIP HOME PHONE ( ) ALT. PHONE ( ) E MAIL GENDER BIRTHDAY AGE SCHOOL OWNERS NAME T-SHIRT SIZE S M L X 2X 3X CAMP FEES AND SCHEDULE Space is limited to 120 Campers CAMP FEE IS $399 REGISTER BEFORE AUGUST 1 ST AND PAY ONLY $349 ONE DAY CAMP CHECK IN AFTER LUNCH ON SATURDAY $199 ALL REGISTRATION FEES AND FORMS SHOULD BE SENT TO ATA MARTIAL ARTS 3940 CHEROKEE ST. SUITE 502 KENNESAW GA Make Checks Payable to ATA

2 CHECK IN STARTS AT 1 PM ON FRIDAY 23rd MASTERS WORKOUT 3:00 PM MASTERS MEETING AT 4:00 PM FIRST LINE UP 5:00 PM REGIONAL TESTING SUNDAY MORNING 25TH CAMP WILL END AT 1 PM ON THE 25TH INCLUDED WITH CAMP: FRIDAY DINNER SATURDAY BREAKFAST, LUNCH AND DINNER SUNDAY BREAKFAST 2 CAMP SHIRTS 3 DAYS OF AMAZING TRAINING YMCA CAMP HIGH HARBOUR 40 OLD SANDTOWN ROAD SE. CARTERSVILLE GA ITEMS TO BRING TRAINING ITEMS COMBAT GLOVES SPARRING GEAR LONG PANTS EXTRA T-SHIRTS REBREAKABLE BOARD FORARM PADS FOCUS MIT PRACTICE KNIFE AND GUN COMBAT BOHNG MOHNG EE (2) PERSONAL ITEMS SLEEPING BAG AND PILLOW SWIM SUIT TOILETRY ITEMS SNACK FOOD AND DRINK TOWEL AND WASH RAG 2 PAIRS OF SHOES SUNSCREEN FLASHLIGHT

3 RANK TESTING OR MID TERM NAME ATA# CURRENT RANK INSTRUCTOR SIGNATURE TESTING MID TERM TESTING FEE 1 ST AND 2 ND DEGREES $150 MID TERM FEES 1 ST AND 2 ND DEGREES $50 3 RD $100 4 TH $135 5 TH $165 PLEASE INCLUDE PAYMENT WITH YOUR REGISTRATION

4 EVENT WAIVER AND MEDICAL INFORMATION NAME APPLICANTS AGE HOME PHONE ADDRESS CITY, STATE, ZIP IN CASE OF EMERGENCY CONTAT: NAME RELATIONSHIP HOME PHONE ALTERNANT PHONE STATEMENT OF UNDERSTANDING/MEDICAL INFORMATION I am aware in signing this statement for participation in the ATA region 108 training camp that certain activities are physically demanding. Therefore, physical fitness will increase your enjoyment and ability for participation in the activity. If for any reason you question your ability to participate in the activity, please consult with your instructor prior to participation. Please note that most activities are conducted outdoors so proper dress is essential to avoid exposure to the elements. The instructors of the camp will take every reasonable precaution to minimize exposure to known risk, however, as a participant you acknowledge the nature of the activity and the fact that not all of the stresses and hazards connected with the activity can be foreseen. You have the personal responsibility to follow the established safety rules and procedures to the extent that you participate in such activities. If at any time you have question about the activity, you have the responsibility to consult with your instructor. I recognize that there is a significant element of risk in any adventure, sport or activity. Knowing the inherent risks, dangers and rigors involved in the activities, I

5 certify that my family and I, including any minor children, are fully capable of participating in the activities. I assume full responsibility for my family and myself, including any minor children, for bodily injury, death, loss of personal property and expense thereof, as a result of my family member (s) participating in the ATA region 108 training camp. Print Name Signature Date (If 18 or under parent or guardian must sign) EMERGENCY MEDICAL INFORMATION YES NO Allergies to foods, drugs, insect bites, stings, dust. If yes please, identify them and you re/ their reaction. YES NO Physical disabilities or conditions, which might limit your/child participation. If yes please, identify them and your/child reaction. YES NO If you/child are presently taking medication, please identify them. MEDICAL AUTHORIZATION

6 If an illness or injury develops, medical and/or hospital care will be provided and I will be notified as soon as possible. I will not hold ATA, camp facility, or its employees for any injury damage received by me or my child while he/she is being transported or is engaged in this activity. I understand and accept the above statement and further authorize each of the following: A. The health history is correct and the participant has my permission to engage in all program activities. B. I authorize medical care units to release medical record information to the health insurance carrier. C. I grant permission to the attending physician to employ such diagnostic procedures and medical treatment as deemed necessary. D. I understand that I am financially responsible for charges not covered or paid by the ATA member insurance and hereby guarantee full payment to the attending physicians and or health care unit. Print Name Signature Date (If 18 or under parent or guardian must sign) MAKE CHECK PAYABLE TO ATA