2009 International Judo Camp by CedricFebis

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									                     2009 Camper Application
            New York YMCA Camp                                                          INTERNATIONAL JUDO CAMP
                                                                                                                                                                                                           DATES                                                                         What Parents Say                                            2009 International
            We’re Here for Good.                                                        PARTICIPATION APPLICATION                                                                            2009 Judo Camp Dates
                                                                                                                                                                                                          August 16 -22
                                                                                                                                                                                                                                                                                                                                                        Judo Camp
                                                        CAMPER INFORMATION                                                                                                                                                                                                                             “This is a weeklong family reunion for                       August 16-22
                                                                                                                                                                                                                                                                                                        the judo community and everyone               37th Year - Oldest Judo Camp in America!
                                                                                                                                                                        2009 Sunday Open Houses!
                                                                                                       /     /                                   Sex:  M     F

Last Name                                       First Name                              MI            Birth date              Age                       Sex
                                                                                                                                                                                                                                                                                                        is family... Best part: a whole week
                                                                                                                                                                                                                                                                                                         surrounded by people who share a
                                                                                                                                                                                 1-4 pm                                                                                                                  passion for a sport that our families
PO Box #          Apt#            Street Address                                 City                                     State             ZIP Code

                                                                                                                                                                                                                April 19                                                                                  and coworkers rarely understand.”
(            )
                                                                                                                                                                                                                 May 3                                                                                                              –M Williams,
Home Phone                                      Judo Club/Team Name                                          Camper Email (optional)
                                                                                                                                                                                                                May 31                                                                                           Columbia University Judo Club
    Free T-Shirt if registered by July 24, 2009:  Youth S        Youth M      Youth L      Adult S      Adult M    Adult L          Adult XL     Adult XXL

                                                                                                                                                                                                                                                                             A Total Pleasure! week!
                                                                                                                                                                                                Come see camp and meet our fine staff!
                                                                                                                                                                                                                                                                                        great
                                                          FAMILY INFORMATION                                                                                                                    If these times are not convenient, please
                                                                                                                                                                                                     contact us for an individual tour.
                                                                                                                                                                                                                                                                               What a
Camper lives with:        Both Parents     Mother      Father       Self      Other (specify):

                                                                                                                                                                       Busing from Manhattan is available. Adults $25. Children ride free.
YMCA Member #               YMCA Branch Name                      Roommate Request: (One request per camper. Each camper must list the other)
                                                                                                                                                                                 Call today to reserve your seat 845.858.2200
                                                             (          )                         (           )

1st Parent / Guardian & Relationship                         Work Phone                           Cell                            Email
                                                                                                                                                                        Plus Great Camp Fun at the                                                                                                                                 Non-Profit Org.
                                                                                                                                                                                                                                                                                                                                    U.S. Postage
Occupation                        Business Name & Address

                                                             (          )                         (           )
                                                                                                                                  Work Email
                                                                                                                                                                         New York YMCA Camp - a                                                                          P.O. Box 622
                                                                                                                                                                                                                                                                         300 Big Pond Road
                                                                                                                                                                                                                                                                                                                                       PAID
                                                                                                                                                                                                                                                                                                                                   Permit No. 461
                                                                                                                                                                                                                                                                                                                                   Port Jervis, NY
                                                                                                                                                                                                                                                                         Huguenot, New York 12746
2nd Parent / Guardian & Relationship                         Work Phone                           Cell                            Email
                                                                                                                                                                       leader in camping since 1881
Occupation                        Business Name & Address                                                                         Work Email
                                                                                                                                                                                           •	   Ca ei g
                                                                                             (         )                          (          )
                                                                                                                                                                                           •	   C i bi g	T e
Other Emergency Contact Name & Relationship                                                  Phone                                Cell                                                     •	   Hii g	 	 i e 	 f	 ai
                 The information below is optional and used only for statistical purposes. Please check appropriate information. Thank you.                                                •	   H ebac	Ridi g	(addi i a 	fee)
                         Racial/Ethnic Category:  American Indian or Alaskan  Asian or Pacific Islander            African American                                                     •	   Nigh 	Hie
                                                     Hispanic       Caucasian          Other _________                                                                                  •	   S f ba                                                                                                                                                        Yonah Melnik, Guest Instructor Israel
                                                                                                                                                                                           •	   S i    i g	
                                                                                                                                                                                           •	   Re a 	a 	 	 ae ide	Ca ee 	a d	S           dec                                                                                                         George Harris, Director, International Judo Legend
                                    PARTICIPANT AGREEMENT & REFUND POLICY                                                                                                                  •	   R b a                                                                                                                                                       George Pasiuk, Director, Grand Champion
                                                    Please READ & SIGN this statement.                                                                                                     •	   Te i
I give permission for me / my child to attend camp. I agree to pay the balance of camp fees on or before July 24, 2009. I understand I will receive a
full refund minus $100 deposit & $20 YMCA Membership Fee if cancelled by June 1, 2009. No refunds after June 1st. I understand I will receive no
refund if my child is sent home for any reason. I grant camp permission to take and publish photographs, videotapes, and recordings of the camper
registered above. I acknowledge that you will be the sole owner of all rights arising out of their use for all purposes and that I shall receive no                     “The YMCA of Greater New York is a community service organization which provides positive
                                                                                                                                                                                                                                                                                                                                                                      New York YMCA Camp
compensation for their use.
                                                                                                                                                                        values through programs that build spirit, mind and body, welcoming all people, with a focus                                                                                                  We’re Here for Good.
Please send a deposit of $10, plus a $20 YMCA membership fee for non-members with your application.                                                                        on youth. Participants are accepted regardless of race, color, national origin or religion.
                                                                                                                                                                          Financial assistance is available for all YMCA programs. Please call for more information.”                                                                                                 Since 1881, a world leader in summer
                                                                                                                                                                                                                                                                                                                                                                      camping. Join us for safe adventures,
Parent / Guardian / Adult Participant Signature                                                                    Date
                                                                                                                                                                                                                                                                                                                                                                      global friendships and YMCA Values!


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                                                                                                                                                                         Apply Online: www.ymcanyc.org/judo 845.858.2200                                                  Apply Online: www.ymcanyc.org/judo 845.858.2200                             Apply Online: www.ymcanyc.org/judo 845.858.2200
                                                                                                                           World-Recognized Instructors                                                                                         The Dojo
                                                                                                                         Yonah Melnik                                         Bill Montgomery                      •	 10,000	square	foot	Fieldhouse	surrounded	by	walls	of	windows	                                                                                              Camper's Last Name                            Camper's First Name
                                                                                                                         Guest Instructor; Judo Olympian 1976 &               5th Dan; Coaching Certification         for cross ventilation and comfort
                                                                                                                         1980,	14- i e	Na i a 	J d 	Cha i 	 f	                                                     •	 4,000	square	feet	of	puzzle	mats
                                                                                                                         Israel, Maccabiah Games Judo Champion                Mike Berkowitz
                                                                                                                         1973	&	1977,	2-Ti e	G d	Meda i 	a 	 he	              3 d	Da ;	N    i g	S aff              •	 Shower,	locker	rooms	and	sauna                                                                                         SESSION & PAYMENT INFORMATION
                                                                                                                                                                                                                                                                                                                                     Additional financial assistance is availabl e. Please call for more information.
                                                                                                                         Sca di a ia 	J d 	O e ,	G d	Meda i 	
                                                                                                                                                                              Heiko Rommelmann                     •	 Weightlifting	&	cardiovascular	training	equipment                                                                                Session 1: August 16th – 22nd
                                                                                                                         a 	 he	Be gia 	J d 	O e ,	2-Ti e	B     e	            4th Dan; Recreation Director
                                                                                                                         Medalist at the British Judo Open                                                         •	 Complete	training	room

       2009 International Judo Camp                                                                                      George Harris
                                                                                                                         C -Di ec ;	9 h	Da ;	O         ia ,	4-Ti e	
                                                                                                                                                                              Penny Druso
                                                                                                                                                                              Director of Counselors
                                                                                                                                                                                                                   •	 Trainers	&	medical	attention	available	24/7
                                                                                                                                                                                                                                                                                                                                     This year’s fee: $588
                                                                                                                         Grand Champion                                                                                                                                                                                                                                                                    =
                                                                                                                                                                              Judo Camp Alumni                                                                                                                             Late fee of $50 if registered after July 24, 2009
              Expert coaching and skill development for players of all ages
                                                                                                                                                                                                                          A+ Training for Coaches
                                                                                                                         George Pasiuk                                        Ce i a	Sch 	(US)
              •	    4:1	ca e 	 	i        c 	ai !                                                                         C -Di ec ;	6 h	Da ;	P e ide 	Me               ia 	   Li i 	Oga a a a	(US)                                                                                                Voluntary Contribution - I want to help a deserving child attend camp; please accept my Strong
                                                                                                                         Judo Association                                                                                                                                                          Kids Campaign Donation:  $35  $55  $100  $200  $ _________
              •	    Safe	a d	f 	e i        e                                                                                                                                  Ed	Liddie	(US)

                                                                                                                                                                                                                               and Referees
                                                                                                                                                                                                                                                                                                                                                                                                           =
              •	    Ca i g,	e e ie ced	c        e                                                                                                                             E e	A     ff-T a e a	(US)
                                                                                                                         Clyde Worthen                                                                                                                                                                      Horseback Riding Lesson - A single riding lesson per session.  $35
              •	    S a e- f- he-a 	faci i 	 i h	Ta a i	 a                                                               6th Dan; National Champion                           J h 	Sa     	(US)                                                                                                                                                                                                            =
                                                                                                                                                                              Ja     	M i 	(US)
                                                                                                                                                                                                                                                                                                                      YMCA Membership Fee for non-members.  $20
                                                                                                                         Jim Bregman                                          F edd 	G c	(US)                       Certification for Local and Regional Referee Licenses                                                                                                                                 =

              The Daily Program Provides Balance                                                                         9th Dan; 1964 Olympic Bronze Medalist                Pe e 	Sei e bache 	(A     ia)          •	   The	most	extensive	training	for	aspiring	referees	in	the	country                                                                                                        Total $
              •	    Begi 	 i h	Tai	Chi	 	j g	a	 ce ic	    ai 	 ai                                                                                                             P chie	M g e 	(US)                     •	   Learn	from	International	Judo	Federation	International	
                                                                                                                         Nagayasu Ogasawara                                                                                                                                                                                                   (See requirement below) Enclosed Deposit $
              •	    M i g	a d	af e         	c a e 	i 	 a 	g                                                              8th Dan; author of Textbook of Judo,                 Ma ee 	B a ie 	(US)                         “A” referees with:
              •	    A	dai 	Ka a	c i ic	f 	 he	f   a 	de     a i 	a d	i       ci   	 f	 ech i   e                         former West Point Coach                              Ma i a	Ped a	(US)                      	    -	5	h     	 f	c a       	 e	 e ie                                                                                                 Total Amount Due July 24, 2009 $
              •	    Se f-defe e	c a e                                                                                                                                                                                	    -	M c	c        eii   	 i h	i    c   	c       e i g	 ia	 i e e   	 adi
                                                                                                                         Harry Glackin                                        Previous Guest Instructors
              •	    E e i g	Ra d i	 	 ac ice	 e 	 i                                                                     Se f-defe   e	a d	Tai	Chi	I     c    ;	7 h	Da                                               	    -	5	H      	 f	Vide 	A a i
                                                                                                                                                                              Pa 	B i 	(US)
                                                                                                                                                                                                                     	    -	9	H      	 f	O -The-Ma 	Se i
                                                                                                                                                                              B e g	K 	Ah 	(K ea)
                                                                                                                         Rick Celotto                                                                                	    	 Sig a 	d i                                                             Minimum
                                                                                                                                                                                                                                                                                                                            $20 (YMCA Membership Fee for non-members) + $100 = $ ______________
                                                                                                                         7th Dan; International Judo Federation Class         T    	MacC      e 	(G ea 	B i ai )                                                                                   Deposit Required
                                                                                                                                                                                                                              Procedures drills
                                                                                                                         “A” Referee                                          J 	B      i g	(H a d)
                                                                                                                                                                                                                              Positioning                                                                                    Check/ Money Order (made payable to New York YMCA Camp)
                                                                                                                                                                              R ia 	Ma h e  	(U ai e)                                                                                            Type of Payment
                                                                                                                         Bonnie Korte                                                                                         Unorthodox Osaekomi                                                                           Credit Card:  MasterCard  VISA  American Express
                                                                                                                                                                              S e e 	Ga e 	(P a d)
                                                                                                                         8th Dan; British Open Gold Medalist;                                                                 Invalid gripping
                                                                                                                                                                              K.G.	Mehdi	(B a i )
                                                                                                                         10-Ti e	US	Na i a 	Cha i                                                                             Prohibited acts
                                                                                                                                                                              H 	Sa 	Ha 	(Ge a )
                                                                                                                                                                                                                     Earn Coaching Certifications                                                  Card Number                                     Verification Code (3 digits MC/V, 4 digits AmEx)                      Expiration Date
                                                                                                                         Sid Kelly                                            T i hia 	Oada	(Ja a )
                                                                                                                         8th Dan; 1999 World Masters Champion;                Rad i 	K ace ic	(Y g a ia)             •	   Level	E	Certification:                                                                                                                                                                           (         )
                                                                                                                         British International Player                         A ge 	Pa i i	(F a ce)                  	    -	C di i   	 f	 ea i g
                                                                                                                                                                                                                                                                                                   Name on Credit Card                                                 Signature                                           Daytime Phone #
                                                                                                                                                                              S 	Cha 	Lee	(K ea)                    	    -	Ph ica 	de e     e
                                                                                                                         David Kiang                                                                                 	    -	The	 echa ica 	 i ci e 	 f	J d
                                                                                                                         5 h	Da ;	K d a -Ce i ed	Ka a	I           c          Ji     	Ped 	(US)
                                                                                                                                                                              Be a d	Le f f e 	(US)                 •	   Level	D	Certification:
                                                                                                                         Noriyasu Kudo                                        A a 	Pe he b idge	(G ea 	B i ai )      	    -	C ic a	a d	 e     	 a
                                                                                                                         8th Dan; Judo Instructor, Tokyo Police               L 	Li cha	(A       ia)                	    -	De e   e 	 f	 ai i g	d i
                                                                                                                                                                              Pe e 	Sei e bache 	(A      ia)         •	   Level	C	Certification:
                                                                                                                         Konstantyn Tshovrebashvili                                                                                                                                                Mail completed form to:                                                                                   CANCELLATION POLICY
                                                                                                                         5 h	Da ;	7-Ti e	U ai ia 	Na i      a	               M ha      ed	Maach	(M cc )             	    -	De e   e 	 f	I eg a ed	A ac	S          e   	f 	i di id a 	 a e        Camp Registrar                                                                                            Full refund minus $100 deposit &
                                                                                                                         Champion                                             A d e	T     ache  	(R     ia)                                                                                       New York YMCA Camp                         Questions? Call our Camp Registrar:                            $20 YMCA Membership Fee if
                                                                                                                                                                                                                     •	   Certification	courses	by	Bill	Montgomery	and	George	Weers                PO Box 622                                 Phone: 845-858-2200                                            cancelled by June 1, 2009
                                                                                                                                                                              Y ichi 	Ma          a	(Ja a )
                                                                                                                         Joe Walters                                                                                 •	   1	hour	daily                                                             300 Big Pond Road                          Fax: 845-858-7823
                                                                                                                                                                                                                                                                                                                                                                                                                                     st
                                                                                                                         5 h	Da ;	1994	W     d	Ma e 	Si e 	Meda i                                                                                                                                  Huguenot, NY 12746-0622                    E-Mail: camps@ymcanyc.org                                      No refunds after June 1
                                                                                                                                                                                                                     •	   Certification	fee:	$25	plus	$15	materials	fee

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                   year!                                     I’ll be back                 Outdoor Adventur
                                                                          next year!                       es
                                                                                                                              Apply Online: www.ymcanyc.org/judo 845.858.2200                                       Apply Online: www.ymcanyc.org/judo 845.858.2200

								
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