Pukulan Camp Waiver

Name *
Name
Home Address *
Home Address
Phone *
Phone
Vegetarian? *
Authorization for Medical Treatment
I hereby authorize One with Heart Fighting Arts located at 4231 SE Hawthorne BLVD, Portland, OR 97215 (503) 231-1999, to consent to any normal and/or emergency medical, and/or surgical treatment which named party deems advisable if emergency contact cannot be reasonably located through the information set out below when person is brought in for treatment.
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Address *
Emergency Contact Address
Emergency Contact Phone Number *
Emergency Contact Phone Number