33rd International Hapkido &
Korean Martial Arts Clinic

September 24, 25 and 26,  2010
USKMAF HQ

Jackson,  Mississippi

For questions call: (601) 856-8487

FRI.  6:00 P.M. - 9:00 P.M.
SAT. 
9:00 A.M. - 7:15 P.M.
SUN. 
10:00 A.M. – 1:00 P.M.

          FEE:  $100 at the door;  $80 Pre-registered by 100 at the door;  $80 Pre-registered by September 14, 2010

Save $20 by Pre-registering!

"Make all checks payable to J.R. West."

[[  OPEN TO ALL BELTS  -  AGES 15 AND ABOVE    [[

All sessions will be held at
West's HapKiDo Academy
291 Highway 51
Ridgeland, MS 

------------------------------------------------------------------------------------------  
32nd International HapKiDo & KMA Seminar

September 24, 25 and 26, 2010

REGISTRATION FORM

Mail to:  GM J. R. West
                45 Wintergreen Road
                Madison, MS  39110

 

NAME ________________________________ PHONE  (__________)________________________

DATE OF BIRTH____________________   Email Address_________________________________

 HOME ADDRESS _________________________________________________________________

  CITY ___________________________ STATE ______________  ZIP___________________

 RANK ____________  STYLE ____________________ INSTRUCTOR _____________________

 SCHOOL NAME ________________________________________________________________

 SCHOOL ADDRESS ___________________________________________________________

 CITY __________________________________   STATE ________  ZIP ___________

 ORGANIZATIONAL AFFILIATION ____________________________________________

RELEASE:   For and in consideration of the use and membership of West's Hapkido Academy, Inc. facilities and other good and valuable considerations allowed by West's Hapkido Academy, Inc., I do hereby for myself, my heirs, executors, administrators, personal representative and/or assigns fully and forever remise, West's Hapkido Academy, Inc. and all other persons, firms, or corporations from any and all claim or claims, demands, injuries, damages, actions, causes of action, suit or suits or anything whatsoever resulting or to result to me by reason of any accident or injury that may occur during my voluntary use of said facilities.

          I do covenant with each and all parties released that I will hold them forever harmless and indemnify them and each of them from any and all claim or claims hereafter presented by any persons, firm, or corporation. I hereby authorize any and all photographs taken at this event to be used in any manner by the USKMAF or West’s HapKiDo Academy Inc.

 I understand that no refunds will be made after September 14, 2010.  
Certificates of completion are awarded Saturday evening to those who pre-register.

 NAME______________________________________DATE_______________________

PARENT/GUARDIAN SIGNATURE____________________________________________________
 
(IF UNDER 18 YEARS OF AGE)