MAIL MAIL REGISTRATION TO KKIA (TYPE IN INFO AND PRINT)
KKIA
1205 N Melrose Dr, Suit., A
Vista, CA 92083
(760) 815-1254
shorinkansandiego@yahoo.com
NAME:
MIDDLE:
STATE:
ZIP:
LAST NAME:
ADDRESS:
TELEPHONE NUMBER:
E-MAIL:
SCHOOL NAME:
SCHOOL INSTRUCTOR:
SCHOOL ADDRESS:
SCHOOL EMAIL:
SCHOOL TELEPHONE:
BELT COLOR:
M/F
AGE:
PLEASE PLACE  YOUR AGE NEXT TO THE DIVISION YOU WISH YOU COMPETE INN
AND A
N/A IN THE DIVISIONS YOU WILL NOT COMPETE INN.
Beg
Int:
Adv:
VIP:
$
BEGINNER @ 10:20 AM COST #25.00
PLEASE NOTE: ANYONE WHOM HAS PAID FOR
NOVEMBER CAMP BY SEPT 20TH.  WILL GET A
$10 DISCOUNT.  THEIRFORE ON THE RIGHT SIDE
YOU WILL ENTER N/A FOR EACH OF THE SLOTS
AND PLACE A $35 IN THE VIP SPOT.
$
INTERMEDIATE @11:15 AM COST $45.00
ADVANCE / BLACK @ 1:30 COST $45.00
$
VIP PRICE OF $35.00
ADD THE $ AMOUNT ON THE RIGHT. IF NOT ENTER A
DIVISION FILL IN WITH A  
N/A. DON'T FORGET YOUR TOTAL
$
$
TOTAL:
Your Name:
As it appears on Credit
Card
First Name
Last Name
Credit Card Number:
VISA or MASTER CARD
Expiration:
3 Digit Security Code:
Behind Card
$
TOTAL:
Hold Harmless Waiver and Release

I understand that karate is a contact sport. As such, I am aware that I am participating in an activity that involves physical
contact and injuries may occur, which may potentially involve great bodily harm or even death and I do so at my own risk. I
waive any claim or cause of action I may have against the promoters of the event, the judges, and other competitors,
and any other affiliated or instructor or entities. I further agree not to indemnify and hold harmless to the promoters, judges,
and any other affiliated in instructor or entities from any and all causes of action or claims which may arise from another
competitor due to my participation or actions in this event. I state that I do not suffer from any physical and mental conditions,
which may affect my participation in this event. I further agree to conduct myself in a sportsmanlike manner and understand
that if I fail to do so, I may be ask to leave from the event and not entitled to a refund. Placing your name bellow will serve as
an electronic
SIGNATURE: Please type name.
Comments:
Enter starting street address:

City, State or Zipcode:
EVENT DIRECTIONS:  1205 N Melrose Dr, # A, Vista CA, 92083
SEMINAR ONLINE
REGISTRATION
Calander