Summer Camp Application
Sun Chong’s Tae Kwon Do
8020 East Genesee Street
Fayetteville NY 13066
 Ph.: 315-637-6192
Fax: 315-637-1441
www.sunchongstkd.com
Camper’s Name ________________________________________ sex: m ___ f ___
Address:# and street __________________________________________________________
City ___________________________________ zip _________________________
Birth date_________________________ age __________ home phone ________________________
Father’s name _____________________________________ work phone ________________________
Mother’s name _____________________________________ work phone ________________________
Emergency name ____________________________________ day phone _________________________
Relationship to camper ___________________________
Child’s physician name: _________________________________ phone ________________________

Health History
List any allergies to foods, medications, or the environment, any recurring illnesses and / or any specific medical illnesses / conditions: ______________________________________________________________________________________
______________________________________________________________________________________
IMPORTANT: Please notify Sun Chong’s Tae Kwon Do if your child is exposed to any communicable diseases prior to or during camp.
Have any significant events occurred in your family within the last few years? ____________________________
Will your child be bringing any medications to camp? ________________________________________________
Does your child have any serious fears? If so, please elaborate _________________________________________
Does your child have any kind of physical handicap / limitation? _______________________________________
Are there any problems which may confront your child while at camp? (i.e.: anxiety, homesickness, moodiness, etc.)? _______________________________________________________________________________________

     Parent’s Authorization: The health history is correct so far as I know, & the person herein described has permission to engage in all prescribed camp activities, except as noted by me. In the event I cannot be reached in an emergency, I hereby give permission to the physician &/or hospital selected by Sun Chong’s Tae Kwon Do in compliance with Onondaga County Health Regulations to hospitalize, secure proper treatment for, & order injection, anesthesia or surgery for my child as named above. NO MEDICAL INSURANCE IS CARRIED BY SUN CHONG’S TAE KWON DO FOR CAMP PARTICIPANTS. REGISTRANTS ARE ENCOURAGED TO HAVE THEIR OWN MEDICAL COVERAGE.
     In consideration of your accepting this registration, I, the undersigned, intending to be legally bound hereby for myself, my heirs, executors & administrators, waive & release and & all claims for damages I may have against Sun Chong’s Tae Kwon Do, & any and all sponsors, representatives, successors & assigns, for any and all injuries suffered by my child in said program.

Parent / Guardian Signature ________________________________________ Date ________________

NOTE: Sun Chong’s Tae Kwon Do Summer Camp is licensed, as required by the New York State Department of Health. This program will be inspected twice this summer and inspection reports will be on file at: Onondaga County Department of Health, Division of Environmental Health, P.O. Box 15190, Syracuse, New York 13215-0190

 

Immunization record received (date) _______________________ initials _____________________