Judo Clinic Flyer - Registration Form and Liability

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Player Registration Form Name ______________________________________________

Age__________

Prior martial arts experience _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _

Email address _____________________________________________________________________________

I have paid/sent the below as $20.00

cash

check (Make checks payable to Frank Barker)

$15.00 * if sent in before pre-registration deadline of February 25th, 2011

Mail forms and registration fee to Anthony Smith, 63 Corley Drive, Rochester, NY 14622 ……………………………………………………………………………………………………………………… Release of Liability On this ______day of __________, 2011 the undersigned hereby releases the College at Brockport and Bushido Kai Judo Club from liability and agrees to indemnify it and hold harmless its employees, representatives and agents for any personal injuries, loss or damage to property arising from activities during the Judo Clinic held on March 6th, 2011. The undersigned agrees to comply with the rules and regulations set by the instructors and coordinators as well as the safety provisions established for the mentioned activity. Participant’s Name ___________

___ Participant’s signature ________________________

Date __________________ For participants below the age of 18 Parent/Guardian Name _____________________ Parent/Guardian Signature ________________________ Date ___________________


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