Christian Sensei Seminar Registration Form

The first clinic is $30 and each additional clinic is $25. Registration and Fees must be received by Anshin Dojo or Renseikan Dojo in advance of the clinics. Make cheques payable to "Renseikan Dojo" (Visa, M/C,Debit in Dojo). For Mudansha please also enter in your belt size and your Kyu rank. Yudansha need only enter their Dan rank. Please select the clinics you wish to attend:

Location	Date	Time	Format	Select
Anshin Dojo	Friday July 13	7pm-9pm	All Karate-Ka	___________
		9pm++	Welcome Party	___________
Renseikan Dojo	Saturday July 14	9am - 11am	Black Belt Only	___________
		12-2pm	All Karate-Ka	___________
		3-5pm	All Karate-Ka	___________
		7-9pm	Adult Karate-Ka	___________
		9pm++	Sayonara Party	___________

Name:________________________ Address:________________________________
Dojo Name:__________________ Sensei Name:____________________________
Age (if under 18):______ Rank (Dan or Kyu #):_____
Belt Size:_____ WMKA Status____

PLEASE READ THE FOLLOWING CAREFULLY

I, the undersigned applicant to the Renseikan Dojo seminar with Fred Christian Sensei, understand that I am applying for instruction in Karate-Do, an activity that involves physical activity. I further understand that the Renseikan Dojo carries no insurance against injury to any of the participants in the seminar.

I hereby acknowledge that I am assuming the risk and responsibility for any and all injuries that I may suffer due to injury, suffered by me, or caused by third parties to me arising out of the practice of Karate-Do, or during the use of any of the facilities available. I further acknowledge that I am responsible for providing my own personal health, medical, dental and accident insurance coverage. I hereby release the Renseikan Dojo, and all of its associated persons from liability for any injury or loss suffered by myself.

DATE_______ SIGNATURE _____________________________
PARENT/GUARDIAN (under 18)___________________________