Videogame Summer Camp

Camper Information

Tell us about your child

Child's Full Name *

Date of Birth *

Age Group *

🟢 Rookies

Ages 5–7

Introduction to gaming culture, teamwork games, and karate basics

🔥 Legends

Ages 8–12

Advanced game strategy, tournaments, and martial arts challenges

T-Shirt Size *

School *

Martial Arts Experience (optional)

Parent / Guardian Information

Primary contact

Primary Parent / Guardian Full Name *

Cell Phone *

Email Address *

Home Address *

Second Parent / Guardian (optional but recommended)

Full Name

Cell Phone

Emergency Contacts

In addition to primary parent — at least one required

Emergency Contact 1 *

Full Name *

Relationship *

Phone *

Emergency Contact 2 (optional)

Full Name

Relationship

Phone

Medical Information

Required for your child's safety — all fields are kept confidential

Allergies (food, medication, environmental — enter "None" if none)

Current Medications (enter "None" if none)

Medical Conditions / Diagnoses (enter "None" if none)

Does your child carry an EpiPen or rescue inhaler? *

✓ Yes — they will bring it to camp

✗ No

Pediatrician Name *

Pediatrician Phone *

Insurance Provider *

Policy Number *

Behavioral & Accommodations

All fields optional — helps our staff support your child

Relevant Diagnoses (ADHD, autism, anxiety, sensory, etc.)

Accommodations that help your child succeed

Triggers or situations that cause difficulty

Strategies that work at home / school when overwhelmed

Pickup Authorization

Only listed individuals may pick up your child — photo ID required

The primary parent/guardian listed above is always authorized. Please list any additional authorized persons below.

Authorized Person 1

Full Name

Relationship

Phone

Authorized Person 2

Full Name

Relationship

Phone

Authorized Person 3

Full Name

Relationship

Phone

I understand that ONLY the people listed above are authorized to pick up my child. Each non-primary-parent pickup requires photo ID every single time, with no exceptions. D3 Martial Arts staff will refuse release to any unlisted person.

Photo & Media Release

Do you grant D3 Martial Arts permission to photograph or video your child for promotional use (social media, website, print, email)? *

✓ Yes — I grant permission

✗ No — do not photograph my child

Your child may still attend camp if you select No.

Liability Waiver & Medical Authorization

Required to complete registration

I have read and agree to the D3 Martial Arts Liability Waiver ↗. I understand participation involves physical activity and inherent risks, and I release D3 Martial Arts, its instructors, and staff from all claims arising from my child's participation. I authorize the camp director to make emergency medical decisions on behalf of my child if I cannot be reached in a timely manner. I authorize emergency medical treatment as necessary.

Digital Signature — Type your full legal name *

By typing your name above, you acknowledge this serves as your legal digital signature for all agreements on this form.

Today's Date *

Payment

Camp pricing & $25 deposit to secure your spot

🏆 Founding Family

$275

Founding Rate

First 10 seats, or until 2 weeks before camp (May 17)

Checking availability…

Standard

$325

Standard Rate

After Founding Families, until 1 week before camp (May 24)

Opens after Founding

Last Call

$375

Last Call Rate

Final week before camp if seats remain (May 25–31)

Opens May 25

How this works: Your $25 deposit (non-refundable) is collected today to secure your child's spot. The remaining balance based on your tier above is due at drop-off on Day 1, June 1, 2026 — credit card on file, Venmo, or check accepted at the front desk.

$25

Non-Refundable Registration Deposit

Balance due Day 1 (June 1) at drop-off: $250 · $300 · or $350 depending on when you register. Payment accepted via credit card on file, Venmo, or check.

Cardholder Name *

Card Number *

Expiration *

CVV *

🔒 Payments processed securely through SPARK Membership. Card data is encrypted and never stored on our servers.