Date:

JUNE 1st 2008

Cost: $80

PLEASE!!! NO VIDEO CAMERAS

Name:

Age:

Address:

City:

Postal Code:

Phone:

E-Mail Address:

Waiver: I hereby submit this application for registration of the above named, for the Shotokan Karate Jutsu, it's instructors / affiliates and Hanshi Patrick McCarthy. I agree to waive all claims against any persons connected with this clinic and likewise assume all responsibilities for any injuries sustained, including but not limited to said seminar and travelling arrangements to and from said seminar.

Signature________________________________ Date_______________________