SAMURAI SWORD SEMINAR
APPLICATION & WAIVER
** You MUST Pre-Register as there will be NO registration or payments accepted the day of the seminar.
E-mail questions: newyorksamurai@aol.com
Name:                                                                                                            Age:                 Birth Date:               
Home Address:                                                                           City:                                 St:           Zip:               
Home Phone:                                                                        Cell Phone:                                                               
Dojo Name:                                                                     Instructor's Name:                                                           
Dojo Address:                                                                                            Dojo Phone:                                         
Style(s):                                                                       How Long:                   Rank(s):                                         
So we can better organize the seminar, please tell us about your martial arts experience:  
                                                                                                                                                                           
WAIVER - MUST Be Completed - NO Exceptions
The above named student, their heirs, executors, administrators (and/or parent/guardian signing on behalf of student) hereby states,
agrees and/or understands the following: This will be a very physically/mentally demanding seminar. Student states they have absolutely
no physical and/or mental limitations whatsoever which would prevent them from participating in long hours of physical and/or mental
challenges and exercises. Student agrees to waive, release, discharge and hold harmless any and all parties from any and all injuries
and/or death including but not limited to New York Budokan, including it's officers/owners, instructors, students, sublets, Samurai Sports,
Action Flex, The Archdiocese of Brooklyn, St. Mary Mother of Jesus School including but not limited to it's staff, the sports program,
volunteers and/or students, St. Mary Mother of Jesus church including but not limited to it's pastor, employees, volunteers and/or
parishioners, other participants, sponsors and/or volunteers at said seminar. Student is responsible for supplying and protecting their own personal items needed for the seminar (please see list). Student gives permission to use their pictures, voices, likeness (including video),
names, dojo name, styles, ranks etc. for advertising and promotional purposes without compensation. In the event of an injury, regardless
of it's cause, student agrees to use and exhaust their own insurance. Students without medical coverage agree to pay their own expenses, medical and otherwise.
Emergency Contact Information
Name:                                                                                   Relation to student:                                                   
Home Phone:                                                                         Cell Phone:                                                              
Student Signature:                                                                                                            Date:                          
Parent Signature (If under 18yrs. Old):                                                                                Date:                        
* If you have your own equipment (Chanbara/Bokken, etc) you're welcome to bring it.
Seminar Address:
* Seminar Time:                                                    NO REFUNDS
Please make check or money order payable to New York Budokan and mail to:

New York Budokan    -    2620 East 18th street , Brooklyn, NY 11235