MFUMO WA FOMU YA KUHUDHURIA SEMINA(SKIF)

MANABU MURAKAMI SHIHAN SEMINAR

REGISTRATION FORM

TRAINING FEES: Pre-registration $120 for entire seminar ($10 discount for active SKIF
members, or $75/ one day (no discount)); Kids (age 16 and under) $40 for entire seminar, or
$25 /one day. (Must be Brown or Blackbelt level for Sunday attendance).
Name _______________________________________________________________________
E-mail _______________________________________________________________________
Address: _____________________________________________________________________
Phone: _____________________________ SKIF-USA Membership #: __________________
Home Dojo: ________________________ Rank: ___________________________________
Adults Youth (15 years and younger)
______ 2 Days (3 sessions) : $120.00 ______ 2 Days (3 sessions); $40.00
______ 1 Day ___ Saturday; ___ Sunday ($75.00) ______ 1 Day ___ Saturday; ___ Sunday ($25.00)
______ Spectator Fee $3.00 ______ Video Pass $20.00
**REGISTRATION is due by SEPTBMBER 26, 2008 - A LATE REGISTRATION FEE
OF $15.00 will be charged after this date/at the door.**

Make payment to: Maine Shotokan Karate Association

PO Box 549, Farmington, ME 04938

Waiver and Release of Liability

I, (Print Name)__________________________, intend to participate in the above open Karate-do Training
Seminar sponsored by New England Shotokan Karate-do, Maine Shotokan Karate Association and/or Rochester
Shotokan Karate Club. I hereby acknowledge that there are possible risks of bodily injury involved in participating
in the special training and related activities. I hereby accept such risks and waive and release any and all claims and
expenses (including but not limited to attorney fees, claims for damages, medical expenses, litigation and other
costs, etc.), either known or unknown, now existing or arising in the future, that I may have of whatever kind or
nature against any organizer, director, member, instructor, owner or anyone else involved in any way with this open
course and associated activities, including but not limited to SKIF-Japan, SKIF-USA, Manabu Murakami Sensei, ,
New England Shotokan Karate-do, James P. Shea, Maine Shotokan Karate Association, Michael F. Cook, Rochester
Recreation Shotokan Karate Club, Steven D. Warren, and/or Rochester Recreation Center, and the City of
Rochester, New Hampshire.
I further agree that any pictures taken of or by me in connection with this open Karate-do course may be
used for publicity or promotion or for personal use by the organizers of this event without compensation to me.
I fully understand this Participation Waiver & Release and I am signing it voluntarily so that I may
participate in the open Karate-do Training Seminar sponsored by SKIF-USA, Manabu Murakami, New England
Shotokan Karate-Do, c/o James P. Shea, Maine Shotokan Karate Association, c/o Michael F. Cook, and the
Rochester Recreation Shotokan Karate Club, c/o Steven D. Warren.
Signature: __________________________________ Date: ___________________________________
Guardian: __________________________________ Date: ____________________________________