Daruma Martial Arts Summer Camp

🗓 Camp Weeks

Select One or More Weeks. All sessions are 9am-3pm. Billing will be handled through Kicksite. *

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Week 1

June 29 – July 3

$600

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Week 2

July 7 – July 11

$600

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Week 3

July 14 – July 18

$600

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Week 4

July 21 – July 25

$600

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Week 5

July 28 – Aug 1

$600

Total $0

🥋 Student Information

First Name *

Last Name *

T-Shirt Size *

👤 Parent / Guardian

Guardian First Name *

Guardian Last Name *

Relationship to Student *

Primary Phone *

Alternate Phone

Email Address *

Home Address *

City *

State

ZIP Code

🚨 Emergency Contact

Must be a different person from the primary guardian listed above.

Full Name *

Relationship *

Phone *

Alternate Phone

🏥 Medical & Health

Known Allergies (food, medication, environmental)

Current Medications

Medical Conditions / Physical Limitations

Primary Care Physician

Physician Phone

Insurance Provider

Can the student self-administer medication? *

Yes No

📋 Additional Information

Dietary Restrictions / Food Preferences

Dietary Notes

Special Needs / Accommodations Requested

How did you hear about Daruma Camp?

Additional Comments

✍️ Consents & Waivers

Please read and acknowledge each item. All items are required.

Parent / Guardian Signature (Full Name) *

Date *

A confirmation email will be sent to the address provided above. Enrollment is pending until payment is processed.