Winter/Spring/Day Camp Application

Father/Guardian Full Name *

Phone Number *

Mother/Guardian Full Name *

Phone Number *

Father/Guardian Email Address *

Mother/Guardian Email Address *

Home Address *

City *

State *

Zip Code *

Emergency Contact Name: *

Relationship *

Emergency Contact Phone *

Secondary Phone

Is either parent Loudoun County Public Schools Staff? *

Where did you hear about DYMA? *

Campers 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)

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

Camps and Attendance

Which camp are you going to attend? *

Which location will you attend? *

Brambleton

Purcellville

Pricing, Terms, and Liability Waiver

Snow Day Camp Day (Hours 10a-4p) (Select Date for Single Day Snow Camps) +

JANUARY DAY CAMP: Which days would you like to attend (January 27th - January 29th)?

Monday (27th) (Hours 8a-6p). Theme: GRAVITY. Field Trip: Altitude Trampoline Park

Tuesday (28th) (Hours 8a-6p). Theme: ROBOTS. Field Trip: Udvar Hazy for STEM Project

Wednesday (29th) (Hours 8a-6p). Theme: BUILDERS. Field Trip: Discovery Museum

APRIL DAY CAMP: Which days would you like to attend (April 4 & April 7, 2025)?

Friday (4th)

Monday (7th)

Pricing

Snow Day Camp $50 (After School Program members FREE) (Not for January or April Camp)

1 day $95 (After School Program member $50)

2 days $180 (After School Program members $100)

3 days $260 (After School Program members $150)

5 days $320 (After School Program member $250)

There will be no refunds. If you would like to cancel you must give 2 weeks notice.

Field trips are subject to change.

Credit Card Type *

Name on Card *

Card Number *

Expiration Date (mm/yy) *

CVV *

Authorization *

I authorize Dragon DYMA Martial Arts to charge my credit card for the week 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 caregiver/physician, etc. DYMA will not be responsible for any liability issues that occurr.

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.

Signature of Applicant/Parent/Guardian *

clear

- By signing this application, student hereby represent that he/she is physically fit to take the prescribed course of instruction.

- I understand and agree that the school will not be held liable for any injuries, damages, losses, etc. Not caused by or resulting for the negligence of the owner, operator, or person in charge of such establishment of employee.

- I understand that once participated it is Non-refundable