2017 ATA Black Belt Camp

(Open to Black Belts 8+)

YMCA CAMP HIGH HARBOUR

40 Old Sandtown Road SE

Cartersville, Georgia 30121

September 22nd, 23rd & 24th 2017

FULL NAME:

ATA NUMBER: RANK:

SCHOOL OWNER:

ADDRESS:

CITY/STATE/ZIP:

PHONE NUMBER:EMAIL:

BIRTHDAY:AGE:GENDER:

T-SHIRT SIZE: S / M / L / XL / XXL / XXXL

* CAMP FEE ($399) AND SCHEDULE SPACE IS LIMITED TO 120 CAMPERS*

**REGISTER BEFORE AUGUST 1ST AND PAY ONLY $349**

ONE DAY CAMP CHECK-IN AFTER LUNCH ON SATURDAY $199

ALL REGISTRATION FEES AND FORMS SHOULD BE SENT TO OR 3940 CHEROKEE ST. SUITE 502 KENNESAW, GA 30144 – MAKE CHECKS PAYABLE TO ATA

CHECK-IN STARTS AT 1:00PM ON FRIDAY, SEPTEMBER 22ND

MASTERS WORKOUT AT 3:00PM& MEETING AT 4:00PM

FIRST LINE UP5:00PM

REGIONAL TESTING SUNDAY MORNING, SEPT. 25TH – CAMP ENDS @ 1:00PM

INCLUDED IN CAMP: 2 CAMP SHIRTS (REGISTER IN TIMELY MANNER TO GUARRANTEE SHIRTS) 3 DAYS OF AMAZING TRAINING AND FUN!! 

  • FRIDAY: DINNER
  • SATURDAY: BREAKFAST, LUNCH AND DINNER
  • SUNDAY: BREAKFAST

ITEMS TO BRING FOR TRAINING: COMBAT GLOVES, SPARRING GEAR, LONG PANTS, EXTRA TSHIRTS, FOREARM PADS AND COMBAT WEAPON. * INSTRUCTORS – REBREAKABLE BOARDS & FOCUS MITTS *

PERSONAL ITEMS TO BRING: SLEEPING BAG AND PILLOW, TOWEL AND WASH RAG, SWIM SUIT, 2 PAIRS OF SHOES, TOILETRY ITEMS, SUNSCREEN, SNACK FOODS, DRINKS, AND FLASHLIGHT

(Please check one if testing or mid-terming)

RANK TESTING MIDTERM

ATA NUMBER CURRENT RANK

TESTING FOR 1ST & 2ND DEGREES - $150

MIDTERM FOR 1ST & 2ND DEGREES - $50 / 3RD $100 / 4TH $135 / 5TH $165

**Please have your instructor call CM Arcemont’s school at 770-427-8400 to give permission for testing. **

EMERGENCY CONTACT

NAME

RELATIONSHIPPHONE NUMBER

STATEMENT OF UNDERSTANDING/MEDICAL INFORMATION

I am aware in signing this statement for a participant in the ATA 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 questions 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 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 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

SignatureDate

(If 18 or younger, parent or guardian must sign)

EMERGENCY MEDICAL INFORMATION

YES OR NO – ALLERGIES to foods, drugs, insect bites, stings, dust. If yes, please identify them and yours or their reaction:

YES OR NO – physical disabilities or conditions, which might limit your/child participation. If yes, please identify them:

YES OR NO – if you/your child are presently taking medication, please identify them:

MEDICAL AUTHORIZATION

If an injury or illness 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 treatments as deemed necessary, (d) I understand that I am financially responsible for charges not covered or paid by the ATA membership insurance and I hereby guarantee full payment to the physicians and/or healthcare units.

Print name (If 18 or younger, parent or guardian must sign)

SignatureDate: