Leadership Martial Arts
Leadership Martial Arts  "Developing leaders through martial arts"  
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Summer Camp Registration
Please complete the form below once for each child

Leadership Martial Arts Membership Information
I am enrolled in LMA martial art classes
I am NOT enrolled in LMA martial arts classes		 

Personal Information
Student Name:
Student Birthdate: //
Parent Name:
Address:
City:
Zip Code:
Your Phone:
Your E-Mail:

Medical Information
Is the student allergic to any medication? Yes No
If so what?
Is the student currently taking medication? Yes No
If so what?
Note any medical problems:
Please list any special dietary needs:
Family Doctor:
Medical/Hospital Insurance:
Policy number:
Doctor's Phone:
Dentist's Phone:

Available Session Dates - Check all sessions you wish to attend!
Session 1: June 14 - 18
Session 2: June 21 - 25
Session 3: June 28 - July 2
Session 4: July 5 - 9
Session 5: July 12 - 16
Session 6: July 19 - 23
Session 7: July 26 - 30
Session 8: August 2 - 6
Session 9: August 9 - 13
Session 10: August 16 - 20
No experience necessary, rank specific training available. Choose one, some or all weeks.  One free week change(transfer) once registered  Additional week transfers cost $25  School/membership/event credit only on cancellations

Age Group & Uniform Size
Genin - Age 5 & 6Uniform Size 000, 00
Chunin - Age 7 & 8Uniform Size 00, 0
Jonin - Age 9 & 10Uniform Size 0, 1
Kage - Age 11 & 12Uniform Size 1, 2, 3


By submitting this form, the student(s) and/or parent or legal guardian acknowledges the existence of certain inherent risks in this type of training and hereby agrees to assume all risks himself. He further relieves Leadership Martial Arts, its management, assigned or contracted instructors and his fellow students from any liability resulting from personal injury and/or loss of personal property. The participant must have medical insurance. The student acknowledges rules and regulations governing the institute have been adopted and may be changed from time to time, and the student agrees to abide by all such rules and regulations adopted, including the time scheduled for instruction and use of the studio as posted. Children with severe behavioral issues interfering with the activities of other campers will be sent home. Parents must arrange for immediate pick up. Management has the right to refuse admission to individuals with prior behavioral issues. Occasional photos or videos of class or special events may be taken. Such materials may be used as advertising media. By submitting this form, claim to all model rights whether active or passive are waived.

By submitting this form, the participant(s) or parent/legal guardian of the above participant(s) give consent for medical emergency care prescribed by a duly licensed Doctor of Medicine, Dentistry, or Emergency Personnel in the event of accident or injury. This can be given under whatever conditions necessary to preserve the life, limb or well-being of the participant(s).
Copyright © 2005 Leadership Martial Arts LLC