Summer Program Information
$80 per day or $120 per week
5:30am – 6:30pm
Dates of Sessions:
Check all that apply
() Week 1: June 4-8 () Week 2: June 11-15 () Week 3: June 18-22 () Week 4: June 25-29
() Week 5: July 2-6 () Week 6: July 9-13 () Week 7: July 16-20 () Week 8: July 23-27
() Week 9: July 30-Aug 3 () Week 10: Aug 6-10 ()Week 11: Aug 12-17
() Week 12: Aug 20-24 () Week 13: Aug 27-31
Total Session Fee: $ ____________ Movie Fee: $ 30.00 .
Breakfast Fee: $30.00 .
Pizza Fee: $30.00 .
Total Program Fee: $ __________ Amount Paid: $ __________ Balance Owed: $ ___________
Please Note: All Fees are non-refundable. Nonrefundable Fees of $120 per week, per participant are due at registration. Total program balance is due on or before June 15.
Participant Code of Conduct
In order to maintain a safe and peaceful environment we require parents and participants to read and comprehend the importance of abiding by the following code of conduct:
I will follow the program’s schedule. I will bring only the items that are required and/or suggested into the program (no weapons, electronic items, etc.). I will respect counselors, directors, and other participants by not using foul language, name calling or fighting. I will follow all safety rules set forth by the program staff.
I agree to help my child abide by this code of conduct.
Parent Signature: ___________________________ Date: __________________________
How did you hear about this program?
7508 Allentown Road
Fort Washington, MD 20744
202-644-2176 | 301-806-0187
Page 1

Participant’s Information
Participant’s Full Name:
__________________________________________________________
Last First
Parent/Guardian’s Name:
_________________________________________________________
Last First
Street Address:
________________________________________________________________
Middle
Middle
Apartment/Unit #
________________________________________________________________
City State ZIP Code
Day Time Phone: _______________________Cell Phone(s): ______________________
E-mail: _________________________________________________________________
Work Phone: _ __________________________ Address: ________________________ _
Grade:_________________________________________________________________
Birth Date: _____________________________ Completed: _______________________
T-Shirt Size (circle one): Child: S M L Adult: M L XL XXL
(Ask for pricing on additional T-Shirts)
Emergency Contact Information
Full Name:
___________________________________________________________________
Last First
Relationship to Participant: ___________________ Phone Number:
___________________
Full Name:
____________________________________________________________________
Last First
Relationship to Participant: ___________________ Phone Number:
___________________
7508 Allentown Road
Fort Washington, MD 20744
202-644-2176 | 301-806-0187
Page 2

Authorization of Treatment:
I hereby give my permission to the medical personnel selected by the program director to order treatment and necessary transportation for my child. In the event I cannot be reached in an emergency, I hereby give my permission to the physician to secure and administer treatment, including authorization for my child named above. (Parent/Guardian must submit completed TRU
MMA and Fitness Summer Program Medical Form prior to the first day of participant’s session).
_______Initials
Release Statement:
I acknowledge that there are natural hazards associated with young kids and related activities in the outdoor setting. I hereby affirm that my child is in good health and physically capable of performing the required activities of this program. In consideration of TRU MMA and Fitness accepting my child and to the extent permitted and provided by State Law, I hereby release and forever discharge TRU MMA and Fitness, its units, agents and employees from all claim of liability for any damages or injuries which may be sustained during my child session (s).
_______Initials
Photo Release:
I hereby give my permission for my child’s picture to be used by TRU MMA and Fitness publications or video programs.
_______Initials
Water Activities:
I understand that the sessions at TRU MMA and Fitness include activities with, near, or in water.
Some sessions with children aged 6 and above may include water reaching 3 feet or more. I give my permission for my child to participate in all water activities included in the sessions. For sessions that include 3 feet or more of water (as noted in program description) participant MUST be able to swim.
_______Initials
Travel:
I give my permission for my child to travel in the company’s van to field trip destinations which correlate with the program’s sessions. I understand that I will be informed of the field trips scheduled for the week.
________Initials
Note : By initialing above, you acknowledge that you have read and agree to each item.
7508 Allentown Road
Fort Washington, MD 20744
202-644-2176 | 301-806-0187
Page 3

All Participants are released at the end of their session day to their parent/guardian or one of the individuals listed on their form. NO EXCEPTIONS! The Staff will release the participant to either parent/guardian listed on the application unless directed by a court to do otherwise.
REMINDER: Photo Identification must be provided at time of pick up.
In addition to names already listed on this application, my child may be released to the following individual(s).
Name:____________________________ Telephone #: ( )___________________
Name:____________________________ Telephone #: ( )___________________
Name:____________________________ Telephone #: ( )___________________
Parent/Guardian
Signature:____________________________ Date: _______________________
Would you like to be updated on schedules and events through email?
If yes, please provide email:
Our summer program is meant to be fun and educational in a safe and recreational environment.
For the benefit of all participants, it is important that children behave appropriately within the summer program. If it becomes necessary to take disciplinary action against a participant, the steps that will be followed are outlined below.
1st incident : The participant will receive a verbal warning and an explanation as to why the behavior is inappropriate (whenever possible, this will be done in a one-on-one setting removed from other participants).
2nd incident : Staff will determine an appropriate consequence for the participant’s actions
(examples may include a “time out” or exclusion from participating in an activity). The participant’s parent/guardian will be notified of their behavior when they arrive to pick up the child.
3rd incident : The participant will be excused from the program without a refund.
The Summer Program Staff of TRU MMA and Fitness reserves the right to bar anyone from the summer program following a first incident in cases of serious behavioral problems.
7508 Allentown Road
Fort Washington, MD 20744
202-644-2176 | 301-806-0187
Page 4

ALLERGIES & DIETARY RESTRICTIONS . Please list, describe reaction and management of the reaction as applicable.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
MEDICATIONS: Please complete the separate Medication Dispensing Information, Permission and
Waiver if you expect the program staff to dispense medication to your child. Children are expected to bring whatever medical supplies or medications they will need each day and turn it into staff, along with written instructions. The medication must be in the original prescription bottle or in a clearly marked container which includes the participant’s name, medication, dosage and time of day medication is to be given. Staff will remind them to take medication. Please list below all medications, including epi-pen, asthma inhaler, over-the-counter or nonprescription drugs, taken regularly, or if they are on a drug holiday.
_______________________________________________________________________________
MEDICATION DOSAGE SPECIFIC TIME TAKEN
_____________________________________________________________________________________
MEDICATION DOSAGE SPECIFIC TIME TAKEN
_______________________________________________________________________________
REASON FOR TAKING
HEALTH INSURANCE / PHYSICIAN
_______________________________________________________________________________
Insurance Company Policy/Group Number Participant ID Number
Physician’s name:_____________________ Office Phone Number: ________________________
IMMUNIZATIONS: .
Are the child’s immunizations current? Yes No
Date of last Tetanus shot ________/________/________
PAST MEDICAL TREATMENT: Please list any major medical treatment, type and date:
_______________________________________________________________________________
_______________________________________________________________________________
NOTIFICATION: Do you want to be notified immediately during the program session for minor injuries (e.g., scrape, non-allergic bee sting, bloody nose, sliver) that do not limit participation in the program? Yes No
7508 Allentown Road
Fort Washington, MD 20744
202-644-2176 | 301-806-0187
Page 5

SPECIAL NEEDS.Are there any physical, mental, psychological or behavioral conditions requiring medication, treatment, orspecial restrictions or considerations during the session(s) of which we should be aware to ensure your child’s fullest enjoyment of their experience? Please describe, including any special accommodations necessary. Please note that it is your responsibility tosupply any necessary medical equipment which relates to a specific medical condition.
Permission to Secure Treatment
In the event of any emergency, I authorize the staff of TRU MMA and Fitness Summer Program
Lake County to secure from any licensed hospital, physicianand/or medical personnel any treatment deemed necessary for me or my minor child/ward's immediate care and agree that I will beresponsible for payment of any and all medical services rendered. I understand that this authorization includes transporting my childby ambulance if necessary to the nearest medical treatment facility or hospital if I am unable to be reached first.
________________________________________
SIGNATURE OF PARENT OR GUARDIAN DATE
________________________________________
PRINTED NAME
7508 Allentown Road
Fort Washington, MD 20744
202-644-2176 | 301-806-0187
Page 6

Time
5:30am – 8:30am
8:30am – 9:00am
9:00am – 11:30am
11:30am -12:00pm
12:00pm – 1:00pm
1:00pm – 1:30pm
1:30pm – 3:30pm
3:30pm – 4:30pm
4:30pm – 6:30pm
Event
Morning Muster
Detail Description
Morning Clean-up
Activity of the Day
Cool Down/ Set up for lunch
Breakfast (meal card holders only)
Toon Time
Quiet activities
Light clean
Square tables and chairs away
Place board games and video games up
Arts and Crafts
Outdoor activities
Free Play
Etc…
Relax
Wash face
Wash hands
Pizza Friday (meal card holders only)
T.V
Lunch Time
Rest
Introduction to Martial Arts History of Martial Arts
Stretching
Exercise
Light Clean / Discussion Points Review
Wrap-up
Free Time Board Games
Video Games
Books
Movie (age appropriate dvd)
Note: This is a sample outline and the days may vary depending on the day and the weather.
Some days we will have field trips and proper notice will be provided. (There may also be a slight fee depending on the activity.)