Karate Camp Registration

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Instructors
- Sensei Ernie Dunkelberger
- Sensei James Harlan
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Home
Instructors
- Sensei Ernie Dunkelberger
- Sensei James Harlan
Training + Pricing
- Belt System
About Wado-Ryu
About Our Dojo
About Karate
Contact
- Directions

Parent/Guardian Name(s)*

Phone Number*

Email Address*

Child's Name*

Date of Birth*

Karate Experience

Child's Name (2)

Date of Birth

Karate Experience

Other Children

Emergency Contact

Pickup Authorization

I authorize staff to seek emergency medical treatment if I cannot be reached. *

Yes

No

I give permission for photos/videos for promotional use. *

Yes

No

I understand karate involves physical activity and risk of injury. I release the dojo and staff from liability except in cases of gross negligence. My child is physically able to participate. *

Yes

No

I understand fees are non-refundable and students must follow dojo rules. Disruptive behavior may result in dismissal.*

Yes

No

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contact sensei

edunk@ptd.net

(717) 333-5882