Winter Camp Registration

Student Information
Full Name
Street Address
City
State
Zip
   
Age
Phone
School
Instructor
Email
   

Parent or Guardian Information
 
Full Name
Work Phone
Home Phone
Emerg. Phone
 

Payment Information
 
Name On Card
Billing Street Address
Billing City
Billing State
Billing ZIP
Billing Phone
Card Type
 
 
Card Number
Exp Date
Sec. Code
 

Transaction Information
 
Camp Fee: $600
MAT Registration Fee: $5
Total Fees: $605
 

Terms & Conditions
 

By clicking submit, I hereby verify the above listed student has my permission to attend the AKA Winter Camp, December 26-29, 2009. I accept full and complete responsibility in case of any injury to my child and or equipment, to, at or from the event. I do not hold the American Karate Association, Sharkey’s Karate Studio or their instructors, students, or staff responsible for any damages, which my child or I may incur.

I give Mr. John Sharkey Jr. full permission to execute any emergency or other medical attention necessary for protection of above said student. This includes any hospitalization or any medical supplies, etc. I also understand that I will be responsible for any medical payments or insurance for the above said student.

Any questions or concerns may be directed to John Sharkey. at 630-369-8055 or email sharkey100@aol.com.

I authorize my card to be charged for the full amount of $605 . I understand that the registration is not valid until my card is authorized. No refunds are allowed except under specially permitted circumstances.