TYPE OF REGISTRATION Hidden
Type of Registration* Type of Registration (after deadline)* CONTACT INFORMATION Name*
First
Last
Address*
Phone*
Email*
PARENT/GUARDIAN INFORMATION Parent/Guardian Name*
First
Last
Parent/Guardian Phone*
Parent/Guardian Email*
PAYMENT TYPE Would you like to pay by check or credit card?* Checks should be made payable to the South Central PA Judo Foundation.
STUDENT INFORMATION All students are required to wear the camp t-shirt due to off-site events.
How many students are your registering? (by check)* How many students are you registering? (by credit card)* STUDENT #1 Student #1 - Name*
First
Last
Student #1 - Age*
Student #1 - Birthday* Student #1 - Gender* Student #1 - Height*
Student #1 - Weight*
T-shirt Size for Student #1* Student #1 - Do you have any food/dietary restrictions or allergies?* Student #1 - If yes, please list/description your food/dietary restrictions or allergies*
Student #1 - Have you attended the Judo Camp in the Past?* Student #1 - If yes, please check the years you have attended* Student #1 - Outside of Camp, does your youth participate in any of the following?* FOR PARENTS/LEGAL GUARDIANS OF PARTICIPANTS OF MINORITY AGE
(UNDER AGE 18 AT TIME OF REGISTRATION)
This is to certify that I, as parent/legal guardian with legal responsibility for this participant, do consent and agree to his/her release, as provided below, of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvement or participation including litigation expenses, attorney fees, loss, liability, damage or costs which may incur as the result of the minor child’s participation in these programs as provided above, even if arising from their negligence, to the fullest extent permitted by law. I have instructed the minor participant as to the above warnings and conditions and their ramifications.Hidden
Student #1 - Parent/Legal Guardian Name* I understand that by typing my name below constitutes a legal signature confirming that I acknowledge and agree to the terms detailed below in this agreement.
First
Last
Hidden
Date - #1*
MM slash DD slash YYYY
STUDENT #2 Student #2 - Name*
First
Last
Student #2 - Age*
Student #2 - Birthday* Student #2 - Gender* Student #2 - Height*
Student #2 - Weight*
T-shirt Size for Student #2* Student #2 - Do you have any food/dietary restrictions or allergies?* Student #2 - If yes, please list/description your food/dietary restrictions or allergies*
Student #2 - Have you attended the Judo Camp in the Past?* Student #2 - If yes, please check the years you have attended* Student #2 - Outside of Camp, does your youth participate in any of the following?* Hidden
USIA WAIVER AND RELEASE OF LIABILITY AND AGREEMENT TO PARTICIPATE* WAIVER AND RELEASE OF LIABILITY AND AGREEMENT TO PARTICIPATE United States Judo Association, Inc., United States Judo Federation, Inc., and USA Judo/United States Judo, Inc., I agree and affirm that: United States Judo Association, Inc., United States Judo together with their affiliated clubs, their respective administrators, directors, officers, agents, coaches, and other employees or volunteers of the organization, event officials, medical personnel, other participants, their
I HAVE READ THE ABOVE WARNING, WAIVER, AND RELEASE, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND KNOWING THIS, SIGN IT VOLUNTARILY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE. I AGREE TO PARTICIPATE KNOWING THE RISKS AND CONDITIONS INVOLVED AND DO SO ENTIRELY OF MY OWN FREE WILL. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/LEGAL GUARDIAN AS EVIDENCED BY THEIR SIGNATURE BELOW. I INTEND THIS TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THAT THE BALANCE, NOTWITHSTANDING SHALL CONTINUE IN FULL FORCE AND EFFECT.
Hidden
Student #2 - Parent/Legal Guardian Name* I understand that by typing my name below constitutes a legal signature confirming that I acknowledge and agree to the terms detailed below in this agreement.
First
Last
Hidden
Date - #2*
MM slash DD slash YYYY
STUDENT #3 Student #3 - Name*
First
Last
Student #3 - Age*
Student #3 - Birthday* Student #3 - Gender* Student #3 - Height*
Student #3 - Weight*
T-shirt Size for Student #3* Student #3 - Do you have any food/dietary restrictions or allergies?* Student #3 - If yes, please list/description your food/dietary restrictions or allergies*
Student #3 - Have you attended the Judo Camp in the Past?* Student #3 - If yes, please check the years you have attended* Student #3 - Outside of Camp, does your youth participate in any of the following?* Hidden
USIA WAIVER AND RELEASE OF LIABILITY AND AGREEMENT TO PARTICIPATE* WAIVER AND RELEASE OF LIABILITY AND AGREEMENT TO PARTICIPATE United States Judo Association, Inc., United States Judo Federation, Inc., and USA Judo/United States Judo, Inc., I agree and affirm that: United States Judo Association, Inc., United States Judo together with their affiliated clubs, their respective administrators, directors, officers, agents, coaches, and other employees or volunteers of the organization, event officials, medical personnel, other participants, their
I HAVE READ THE ABOVE WARNING, WAIVER, AND RELEASE, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND KNOWING THIS, SIGN IT VOLUNTARILY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE. I AGREE TO PARTICIPATE KNOWING THE RISKS AND CONDITIONS INVOLVED AND DO SO ENTIRELY OF MY OWN FREE WILL. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/LEGAL GUARDIAN AS EVIDENCED BY THEIR SIGNATURE BELOW. I INTEND THIS TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THAT THE BALANCE, NOTWITHSTANDING SHALL CONTINUE IN FULL FORCE AND EFFECT.
Hidden
Student #3 - Parent/Legal Guardian Name* I understand that by typing my name below constitutes a legal signature confirming that I acknowledge and agree to the terms detailed below in this agreement.
First
Last
Hidden
Date - #3*
MM slash DD slash YYYY
STUDENT #4 Student #4 - Name*
First
Last
Student #4 - Age*
Student #4 - Birthday* Student #4 - Gender* Student #4 - Height*
Student #4 - Weight*
T-shirt Size for Student #4* Student #4 - Do you have any food/dietary restrictions or allergies?* Student #4 - If yes, please list/description your food/dietary restrictions or allergies*
Student #4 - Have you attended the Judo Camp in the Past?* Student #4 - If yes, please check the years you have attended* Student #4 - Outside of Camp, does your youth participate in any of the following?* Hidden
USIA WAIVER AND RELEASE OF LIABILITY AND AGREEMENT TO PARTICIPATE* WAIVER AND RELEASE OF LIABILITY AND AGREEMENT TO PARTICIPATE United States Judo Association, Inc., United States Judo Federation, Inc., and USA Judo/United States Judo, Inc., I agree and affirm that: United States Judo Association, Inc., United States Judo together with their affiliated clubs, their respective administrators, directors, officers, agents, coaches, and other employees or volunteers of the organization, event officials, medical personnel, other participants, their
I HAVE READ THE ABOVE WARNING, WAIVER, AND RELEASE, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND KNOWING THIS, SIGN IT VOLUNTARILY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE. I AGREE TO PARTICIPATE KNOWING THE RISKS AND CONDITIONS INVOLVED AND DO SO ENTIRELY OF MY OWN FREE WILL. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/LEGAL GUARDIAN AS EVIDENCED BY THEIR SIGNATURE BELOW. I INTEND THIS TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THAT THE BALANCE, NOTWITHSTANDING SHALL CONTINUE IN FULL FORCE AND EFFECT.
Hidden
Student #4 - Parent/Legal Guardian Name* I understand that by typing my name below constitutes a legal signature confirming that I acknowledge and agree to the terms detailed below in this agreement.
First
Last
Hidden
Date - #4*
MM slash DD slash YYYY
STUDENT #5 Student #5 - Name*
First
Last
Student #5 - Age*
Student #5 - Birthday* Student #5 - Gender* Student #5 - Height*
Student #5 - Weight*
T-shirt Size for Student #5* Student #5 - Do you have any food/dietary restrictions or allergies?* Student #5 - If yes, please list/description your food/dietary restrictions or allergies*
Student #5 - Have you attended the Judo Camp in the Past?* Student #5 - If yes, please check the years you have attended* Student #5 - Outside of Camp, does your youth participate in any of the following?* Hidden
USIA WAIVER AND RELEASE OF LIABILITY AND AGREEMENT TO PARTICIPATE* WAIVER AND RELEASE OF LIABILITY AND AGREEMENT TO PARTICIPATE United States Judo Association, Inc., United States Judo Federation, Inc., and USA Judo/United States Judo, Inc., I agree and affirm that: United States Judo Association, Inc., United States Judo together with their affiliated clubs, their respective administrators, directors, officers, agents, coaches, and other employees or volunteers of the organization, event officials, medical personnel, other participants, their
I HAVE READ THE ABOVE WARNING, WAIVER, AND RELEASE, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND KNOWING THIS, SIGN IT VOLUNTARILY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE. I AGREE TO PARTICIPATE KNOWING THE RISKS AND CONDITIONS INVOLVED AND DO SO ENTIRELY OF MY OWN FREE WILL. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/LEGAL GUARDIAN AS EVIDENCED BY THEIR SIGNATURE BELOW. I INTEND THIS TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THAT THE BALANCE, NOTWITHSTANDING SHALL CONTINUE IN FULL FORCE AND EFFECT.
Hidden
Student #5 - Parent/Legal Guardian Name* I understand that by typing my name below constitutes a legal signature confirming that I acknowledge and agree to the terms detailed below in this agreement.
First
Last
Hidden
Date - #5*
MM slash DD slash YYYY
OTHER FUNDRAISING EFFORT TO SUPPORT THE CAMP Hidden
Would you like to purchased additional t-shirts to support the fundraiser* How many extra t-shirts would you like to purchase? (by check) How many extra t-shirts would you like to purchase? (by credit card)* 1 EXTRA T-SHIRT - $25 per T-Shirt* 2 EXTRA T-SHIRTS - $25 per T-Shirt* 3 EXTRA T-SHIRTS - $25 per T-Shirt* 4 EXTRA T-SHIRTS - $25 per T-Shirt* 5 EXTRA T-SHIRTS - $25 per T-Shirt* Would you like to make a donation to South Central PA Judo Foundation?* Enter the amount of your donation (by check)*
Enter the amount of your donation (by credit card)*
WAIVER OF LIABILITY AND CODE OF CONDUCT AGREEMENTS West Shore YMCA, YMCA Independent Contractor and TFEC Release and Waiver of Liability You have registered yourself/your child to participate in a YMCA service that involves physical activity. Completion of this form is required. This document is a release of claims, and by signing it you do the following:
1. Acknowledge that when participating in YMCA activities you/your child(ren) may suffer serious or fatal injury.
2. Certify to the West Shore YMCA Staff, and or YMCA Independent Contractor, Camp Curtain and or TFEC that you are/your child(ren) is in good health and physical condition, sufficient to engage in such activities and that you/your child(ren)’s participation in such activities may be potentially dangerous or harmful to you/your child(ren).
3. Assume the risk of, and release and hold the West Shore YMCA and or YMCA Independent Contractor, Camp Curtain and or TFEC harmless from, any liability for physical or other injury that has been suffered by you/your child(ren) during, or as a consequence of, participation in any physical activity except for physical activity or injury that is caused by West Shore YMCA and or YMCA Independent Contractor, Camp Curtain and or TFEC and you agree that the West Shore YMCA shall not have any liability or responsibility for any such injury or harm except for physical activity or injury that is caused by West Shore YMCA and or YMCA Independent Contractor, Camp Curtain and or TFEC
4. I support the YMCA mission and understand that all YMCA programs are based on participation, fun, physical fitness and personal wellness, skill development, teamwork, fair play, family involvement, volunteerism, and character development. Furthermore, I authorize the YMCA to photograph or video tape myself or my child(ren) and understand that all photos and video footage may be used for publicity purposes.
West Shore YMCA Code of Conduct At the West Shore YMCA, we expect staff, members and guests to behave in accordance with our mission and values at all times, respecting the rights and dignity of others.
At the YMCA we demonstrate
Respect, Responsibility, Caring and Honesty by:
1. Speaking in respectful tones; refraining from the use of vulgar or derogatory language; and dressing appropriately.
2. Resolving conflicts in a respectful, honest and caring manner; never resorting to physical contact or threatening gestures.
3. Respecting others by refraining from intimate behavior in public; abstaining from contact of a sexual nature.
4. Respecting the property of others; never engaging in theft or destruction.
5. Creating a safe, caring environment; never carrying illegal firearms or devices.
6. Participating in programs to build a healthy spirit, mind and body; never engaging in the use, sale, dispensing or possession of illegal drugs or narcotics, or the unsanctioned use of alcohol on YMCA premises.
Adherence to the YMCA Code of Conduct and regulations is essential.
Noncompliance may result in suspension or termination of YMCA membership. USIA WAIVER AND RELEASE OF LIABILITY AND AGREEMENT TO PARTICIPATE* WAIVER AND RELEASE OF LIABILITY AND AGREEMENT TO PARTICIPATE United States Judo Association, Inc., United States Judo Federation, Inc., and USA Judo/United States Judo, Inc., I agree and affirm that: United States Judo Association, Inc., United States Judo together with their affiliated clubs, their respective administrators, directors, officers, agents, coaches, and other employees or volunteers of the organization, event officials, medical personnel, other participants, their
I HAVE READ THE ABOVE WARNING, WAIVER, AND RELEASE, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND KNOWING THIS, SIGN IT VOLUNTARILY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE. I AGREE TO PARTICIPATE KNOWING THE RISKS AND CONDITIONS INVOLVED AND DO SO ENTIRELY OF MY OWN FREE WILL. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/LEGAL GUARDIAN AS EVIDENCED BY THEIR SIGNATURE BELOW. I INTEND THIS TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THAT THE BALANCE, NOTWITHSTANDING SHALL CONTINUE IN FULL FORCE AND EFFECT.
By submitting this registration I am confirming that I have read, understand and affirm that I am/my child(ren) is in good health and physical condition, will follow the Code of Conduct and am submitting this registration of my own free will. I agree to all of the foregoing for anyone listed on this membership. Parent/Legal Guardian Name* I understand that by typing my name below constitutes a legal signature confirming that I acknowledge and agree to the terms detailed below in this agreement.
First
Last
Date*
MM slash DD slash YYYY
CAMP PAYMENT SUMMARY (by credit card) Camp Registration Subtotal
$0.00
Extra T-Shirts Subtotal
$0.00
Donation Subtotal
$0.00
BILLING INFORMATION - PAYMENT DUE (by check) CHECK TOTAL + Number of Extra Shirts Ordered + Additional Donation Amount = Total
TOTAL DUE = $260 If you have a discount code, subtract the amount of the coupon. from your total SUMMARY OF YOUR CAMP COSTS Camper Registration - 1 Camper = $80.00 Camper Registration - 4 Campers = $320.00 Camper Registration - 5 Campers = $450.00 Camper Registration - 3 Campers = $240.00 Camper Registration - 2 Campers = $160.00 Did you purchase any extra t-shirts? Enter the Amont Total Due* This is the amount of the check you will mail to TFEC prior to camp.
BILLING INFORMATION (by credit card) Subtotal (subtotal of camper registration, extra t-shirts and donation)
$0.00
Hidden
Enter Coupon Code if applicable Transaction Fee Total of Transaction Fee
Price:
$0.00
Total
$0.00
Credit Card Payment Information
Email This field is for validation purposes and should be left unchanged.
