2012 kokondo gasshuku
DESCRIPTION
2012 Gasshuku Seminar Flyer and Registration FormTRANSCRIPT
Saturday March 3, 2012 9:00 AM – 4:00 PM
Hartford/Windsor Marriott 28 Day Hill Road • Windsor, Connecticut 06095
JJooiinn oouurr KKookkoonnddoo KKaaiicchhoo aass wweellll aass ootthheerr mmaasstteerr iinnssttrruuccttoorrss ffoorr
aa ssppeecciiaall aallll ddaayy KKookkoonnddoo MMaarrttiiaall AArrttss TTrraaiinniinngg eevveenntt.. TThhiiss iiss aa
vveerryy ssppeecciiaall aanndd eexxttrraaoorrddiinnaarryy ooppppoorrttuunniittyy ttoo eexxppeerriieennccee aann
iinntteennssiivvee ddaayy ffuullll ooff ttrraaddiittiioonnaall kkaarraattee aanndd jjuujjiittssuu!!
All belt ranks 7 Years and older are invited!
22001122 KKookkoonnddoo GGaasssshhuukkuu Sessions Include
Kata and bunkai applications
Individualized kid‐friendly training
Strategy of self defense including timing, speed and distance concepts
Kobudo and modern weapons
Traditional kumite including ippon, sanbon, jiyu and kiso
Randori including renzoku waza applications and advantages
Karate vs Jukido
Taihojutsu / Shime‐waza / Kansetsu‐waza
Special Breakout Sessions
Now, more than ever, don’t miss the opportunity to take part in this special extended training and appreciate the uniqueness that this kind of focused training has to offer all aspects of your life.
COST Adults………$45.00 Children……$25.00 (under 16 years old)
Includes lunch
Registration Payable to: IKA, LLC Late Registration will incur an additional $5.00 fee
Registration must be returned on or before February 27th 2012
Today’s date: GASSHUKU REGISTRATION FORM ‐ 2012
STUDENT INFORMATION Student’s last name: First: Middle: Mr.
Mrs. Miss Ms.
Marital status (circle one)
Single / Mar / Div / Sep / Wid
Belt Rank Jukido Belt Rank karate Dojo / Sensei Name Birth date: Age: Sex:
/ / M F
Street address: Cell phone no.: Home phone no.: Email address:
( ) ( )
P.O. box: City: State: ZIP Code:
Occupation: Employer: Employer phone no.:
( )
IN CASE OF EMERGENCY Name of Contact: Relationship: Home phone no.: Cell phone no.:
( ) ( )
I, hereby both freely and voluntarily give my/our consent and approval for participation in the martial arts sports program described on this form, and further, agree individually to the terms of the waiver, release, covenant not to sue and indemnity agreement as set forth herein below. In case of injury or illness, I give my consent to emergency transportation and the administration of any first aid, medical and/or dental treatment. I accept responsibility for the payment of any such emergency transportation and treatment expenses and any related or subsequent medical bills. I acknowledge that International Kokondo Association LLC (Hereinafter “IKA”) has not purchased and will not provide any medical, health, or accident insurance to cover such expenses and that any such insurance is my/our responsibility. I understand that there are inherent risks in the practice of martial arts, including physical injury and even death. I, individually, assume all risks and hazards incidental to such participation, including, but not limited to, physical injury and transportation to and from activities; and I/we hereby waive, release, absolve, indemnify and agree to hold harmless IKA, the program teachers, coaches, sponsors, supervisors, participants, person(s) transporting me and, IKA members, officers, directors, employees, volunteers, agents or any other representatives of IKA, from and against any and all causes of action, claims, demands, losses, expenses or liability of any nature whatsoever, in law or in equity, arising from the activities contemplated hereby. In the same capacities, I covenant and agree not to sue IKA, the program teachers, coaches, sponsors, supervisors, participants, and person(s) transporting me, IKA members, officers, directors, employees, volunteers, agents or any other representatives of IKA, for any such causes of action, claims, demands, losses, expenses or liability. I understand that conduct by me deemed inconsistent with the rules of sportsmanship and fair play, could result in expulsion from this or any other IKA sponsored activity or program. I have fully read this document, understand its meaning and the legal impact thereof, have had the opportunity to have my/our attorney review this document and explain it to me prior to signing my name below. I voluntarily sign this Waiver, Release, Covenant Not to Sue and Indemnity Agreement. I voluntarily, of my own free will and without distress or coercion sign this waiver, release, covenant not to sue and indemnity agreement.
I understand and agree that a facsimile copy of my signature is just as valid as my original ink signature. If faxing a copy of my signature on the document to the IKA, I agree to mail or otherwise deliver a copy of the original document containing my original ink signature to the IKA within 7 days.
Participant /I f Minor Parent or Guardian signature Date
REGISTRATION AND PAYMENT MUST BE RECEIVED ON OR BEFORE FEBRUARY 27, 2012
Number Attending Qty $ Qty $52 Qty $ Adults (16 years old +)
$45.00 ea Children (under 16 years old)
$25.00 ea TOTAL Student 1 Student 2 Student 3 Student 4 Student 5
Adult (x)
Child (x) Last First M.I.
Address:
Street Address Apartment/Unit #
City State ZIP Code Payment Information: if paying by check please mail to Robert E Robert • 26 Hooker Drive • West Hartford, CT 06107
Check One
Check Payable to IKA LLC
Visa
MC
AMEX
Credit Card Information
Name on Credit Card
Credit Card Number Expiration Date CVV Security Code
CVV is the last 3 digits on the back of your card. For AMEX it's the 4-digit code on the front side.
Return for to: Robert E. Robert 26 Hooker Drive West Hartford, CT 06107 or email to: [email protected] or fax to: 860.292.1114