2025 DYMA SUMMER CAMP REGISTRATION

PARENT/LEGAL GUARDIAN'S INFORMATION

Father/Guardian Full Name *

Phone Number *

Mother/Guardian Full Name *

Phone Number *

Father/Guardian Email Address *

Mother/Guardian Email Address *

Street Address *

City *

State *

Zip Code *

Emergency Contact Name: *

Relationship to Camper *

Emergency Contact Phone *

Secondary Phone

Is either parent Loudoun County Public Schools Staff? *

CAMPER INFORMATION (ages 5+)

Member #1 Full Name *

Member #1 DOB (MM/DD/YY) *

Member #2 Full Name

Member #2 DOB (MM/DD/YY)

Member #3 Full Name

Member #3 DOB (MM/DD/YY)

Which camp are you going to attend? *

Summer Camp

Which location will you attend? *

Purcellville

Brambleton

Is there anything you would like us to know about your child(ren)? (allergies, medication, etc.)

How did you hear about DYMA? *

SUMMER CAMP

Are you new to DYMA or a returning member? *

New Member [$100 One Time Registration Fee]

Returning Member

CAMP DAYS AND RATES

WEEK SELECTION FOR SUMMER CAMP *

Which three days would you like to attend? *for 3 days per week members only*

Pricing, Terms, and Liability Waiver *

$340 Per Member Per Week (5 days)

$260 Per Member Per Week (3 days)

Payment Options *

Pre-Paid Weekly (charged every Friday, prior to the week attending)

Full Paid (charged all at once for the weeks selected)

*Dates may be extended/may change.

- Pack a lunch daily.

If you wish to rotate or cancel any of your selected weeks, you may only do so by providing a 2 weeks written notice. You may or may not be charged an extra fee. There are no refunds.

*We will be closed on Monday, June 19th Juneteenth National Independence Day and July 4th, Independence Day. Field trip locations are subject to change.

There will be no refunds. If you would like to cancel or change your selected weeks, then you will be given a 2 weeks notice.

Payment options have no refunds and will be charged in advance (weekly or in full).

Card Type *

Name on Card *

Card Number *

Exp. Date *

CVV *

Comments

Authorization *

I authorize Dragon DYMA Martial Arts to charge my credit card for the weeks selected, and I understand that there are no refunds regardless of attendance.

Terms and Waiver:
I agree to waive any and all claims against Dragon DYMA Martial Arts and all people connected with it. This contract serves as permission to have my child(ren) transported to any health care facility and for him/her to receive any and all emergency health care should the situation arise.

As we are all aware, children are prone to mishaps. Although Dragon DYMA Martial Arts makes every effort to have adequate supervision, occasionally accidents can happen. In the instance that an emergency arises, we would need your specific permission to transport and have your child treated by a professional care giver/physician, etc. DYMA will not be responsible for any liabilities issues occurred.

For the safety and well being of our students and staff, Dragon DYMA Martial Arts reserves the right to remove any child from our program.

I agree that any picture taken of my child(ren) in connection with the Camp can be used by Dragon Yong-In Martial Arts for publicity or promotion without compensation at this or any other time.

By signing below, I verify that all the above information is correct and that I agree to the terms stated above.

Parent/Legal Guardian's Signature *

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