Black Belt/Kodanja Clinic Registration Form

WTSDA Region 4 Black Belt Summer Camp Registration

Fill out the form per camp participant
DATE: Friday June 26, 4-6 pm (check in) to Sunday, June 28, 11 am (check out starts at 11:30am)

LOCATION:
Trinity University
One Trinity Place
San Antonio, TX 78212

COST/LODGING:
(Includes meals and lodging (4 meals and two nights lodging), training, snacks, water and a Camp T-Shirt for Camp Participant) An additional T-Shirt is $20.

NOTE: Moo Do Society will supplement overhead costs.

$220 per Adult Participant On Campus Lodging
$300 per Child Participant with one accompanying adult On Campus Lodging
$120 Per Child Participant with accompanying adult(s) Off Campus Lodging (covers 4 meals and the participant t-shirt)

NOTE:
- Youth under the age of 18 must stay with parents at all times unless participating within the event. Parents are allowed to stay and view the clinic.
- No minor participant may reside on campus under the age of 12, they must reside off campus and commute.
ARTICLES TO BRING:
We are staying in dorms, so you need bedding (pillow, sheets/blanket for twin size bed or sleeping bag), towels, toiletries, Rule Book (if black belt at least 16 years old), do bohk, protective gear, Association or studio T-shirts, sneakers, bong, dan gum, sword, cane, water and snacks, pen/pencil and paper, and other articles that you think you may need.

Registration Deadline: June 14, 2026 at midnight

Registration Inquiries:
Mr. Brian Toye, Sam Dan
Email: Toye.Brian@gmail.com
Participant Name

First NameLast Name
Birth Date

MonthDayYear
Date
Gender
Student or Parent E-mail
Use Parent/Guardian if under 18)
Phone Number
Format: (000) 000-0000.
Studio
Other: Studio Name
Rank
WTSDA Number
CDBs enter their Gup Numbers. If unknown, see your instructor. Black Belts and Kodanja enter their Dan numbers.
Participant Type
Lodging Type
Number of Accompanying Adults
T-Shirt Size
included with event registration
Additional T-Shirt
$20 for extra T-Shirt
Any special dietary requirements?
Special Dietary Explanation/Specifics:
Emergency Contact Person/Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Personal Physician
Personal Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical History
If none, enter N/A for Not Applicable
Medications
Please include dose and frequency. If none, enter N/A for Not Applicable
Allergies
If none, enter N/A for Not Applicable
Insurance Carrier
Insurance Carrier Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Group #
Additional Comments
Base Camp Cost
Additional Parent Cost
Rank Discount
Total Camp Cost
Checked In
DateTime
I, the undersigned, assume all risks for injury that I may sustain in connection with this seminar and waive claims against instructors, any other students, participating studios, the Regional Director, the World Tang Soo Do Association (WTSDA) and its officials, or hosting facility. I will strictly observe and obey all rules and regulations governing this seminar.
Accept Waiver
Signature
Payment

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WTSDA Region 4 Black Belt Summer Camp Registration

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