Western Pacific Tang Soo Do Coos Bay Registration

Welcome to the 26th Anniversary of the Coos Bay Summer Camp

Below you will find the online "Additional Participant" registration form. You will not be able to make payment(s) using this form.

For those who wish to mail in their registrations or need additional information please download the PDF Registration form for complete Coos Bay Summer Camp information, waivers, and medical releases.

You can send all registrations to the address listed below:

26th Coos Bay Summer Camp
c/o Brooks Matsuda
6630 Flamingo Way
Sacramento, California 95828

Thank you again and see you soon,

Western Pacific Tang Soo Do Association

Additional Participant Name *
Additional Participant Phone *
Additional Participant Email Address *
Additional Participant Rank
WPTSD / WDU-USA Member	WPTSD / WDU-USA Member - Yes WPTSD / WDU-USA Member - No
Dojang Name / Head Instructor *
Emergency Contact Name *
Emergency Contact Phone *
Physician Name*
Physician Phone*
Last Tetanus Shot (month/year) *
Can Participant Swim	Yes No
List all allergies	List all allergies here. If None enter none
Additional Health Factors	Please list any health factors, which make it necessary for the participant(s) to follow a limited or restricted physical activity program at sea level. (I.E. recent surgery, allergies, diet, etc.) List any/all additional health factors here If none enter none
Authorization for Medical Treatment	A parent or legal guardian must sign this “Authorization for Medical Treatment” before medical attention can be administered in the event of an emergency. I hereby authorize the physician contacted by the seminar representative to provide medical or surgical care for the above named participant in any Emergency which may occur while he/she is attending the 2010 Western Pacific Tang Soo Do Association’s Summer Seminar.
Medical Treatment - I Agree	Yes I have read the above statement and I Agree Yes I have read the above statement and I Disagree
Desired Medical Treatment	If you "Disagree" with the above waiver, any other desired action must be specified in writing in this area and check the "I have entered my Medical Desires" in the space provided below.
Desired Medical Treatment 2	I have entered my Medical Desires
Hold Harmless Clause *	I, the undersigned adult, on behalf of myself (and my child(ren) if any such child(ren) are registered as a Participant) agree to indemnify and to hold the Western Pacific Tang Soo Do Association, its affiliates, instructors, officials and agents, while acting within the scope of their duties, harmless from all lawsuits, causes of actions, demands, and claims, including costs of their defense, arising in favor of myself, my child(ren) participant (if applicable), or third parties, on account of personal injuries, death or damage to property arising out of the activities related to the above Summer Seminar activities. Must Agree to waiver to participate.
Hold Harmless Clause 2 *	I Agree to the Hold Harmless Clause I Disagree to the Hold Harmless Clause