Saturday March 3, 2012 9:00 AM – 4:00 PM

Hartford/Windsor Marriott 28 Day Hill Road • Windsor, Connecticut 06095

JJooiinn  oouurr KKookkoonnddoo KKaaiicchhoo aass wweellll aass ootthheerr mmaasstteerr iinnssttrruuccttoorrss  ffoorr  

aa  ssppeecciiaall  aallll  ddaayy  KKookkoonnddoo  MMaarrttiiaall  AArrttss  TTrraaiinniinngg  eevveenntt..    TThhiiss  iiss  aa  

vveerryy  ssppeecciiaall  aanndd  eexxttrraaoorrddiinnaarryy  ooppppoorrttuunniittyy  ttoo  eexxppeerriieennccee  aann  

iinntteennssiivvee  ddaayy  ffuullll  ooff  ttrraaddiittiioonnaall  kkaarraattee  aanndd  jjuujjiittssuu!!   

All belt ranks 7 Years and older are invited! 

    

  

22001122  KKookkoonnddoo  GGaasssshhuukkuu  Sessions Include 

Kata and bunkai applications 

Individualized kid‐friendly training 

Strategy of self defense including timing, speed and distance concepts 

Kobudo and modern weapons 

Traditional kumite including ippon, sanbon, jiyu and kiso 

Randori including renzoku waza applications and advantages 

Karate vs Jukido 

Taihojutsu / Shime‐waza / Kansetsu‐waza  

Special Breakout Sessions   

 

Now, more than ever, don’t miss the opportunity to take part in this special extended training and appreciate the uniqueness that this kind of focused training has to offer all aspects of your life. 

COST Adults………$45.00 Children……$25.00 (under 16 years old)

Includes lunch

Registration Payable to: IKA, LLC Late Registration will incur an additional $5.00 fee

Registration must be returned on or before February 27th 2012

    

Today’s date:  GASSHUKU REGISTRATION FORM ‐ 2012 

STUDENT INFORMATION Student’s last name:  First:  Middle:   Mr. 

 Mrs.  Miss  Ms. 

Marital status (circle one) 

  Single  /  Mar  /  Div  /  Sep  /  Wid 

Belt Rank Jukido  Belt Rank karate  Dojo / Sensei Name  Birth date:  Age:  Sex: 

               /          /     M   F 

Street address:  Cell phone no.:  Home phone no.:  Email address: 

  (          )  (          )   

P.O. box:  City:  State:  ZIP Code: 

       

Occupation:  Employer:  Employer phone no.: 

    (          ) 

IN CASE OF EMERGENCY Name of Contact:  Relationship:  Home phone no.:  Cell phone no.: 

    (          )  (          ) 

I, hereby both freely and voluntarily give my/our consent and approval for participation in the martial arts sports program described on this form, and further, agree individually to the terms of the waiver, release, covenant not to sue and indemnity agreement as set forth herein below. In case of injury or illness, I give my consent to emergency transportation and the administration of any first aid, medical and/or dental treatment. I accept responsibility for the payment of any such emergency transportation and treatment expenses and any related or subsequent medical bills. I acknowledge that International Kokondo Association LLC (Hereinafter “IKA”) has not purchased and will not provide any medical, health, or accident insurance to cover such expenses and that any such insurance is my/our responsibility. I understand that there are inherent risks in the practice of martial arts, including physical injury and even death. I, individually, assume all risks and hazards incidental to such participation, including, but not limited to, physical injury and transportation to and from activities; and I/we hereby waive, release, absolve, indemnify and agree to hold harmless IKA, the program teachers, coaches, sponsors, supervisors, participants, person(s) transporting me and, IKA members, officers, directors, employees, volunteers, agents or any other representatives of IKA, from and against any and all causes of action, claims, demands, losses, expenses or liability of any nature whatsoever, in law or in equity, arising from the activities contemplated hereby. In the same capacities, I covenant and agree not to sue IKA, the program teachers, coaches, sponsors, supervisors, participants, and person(s) transporting me, IKA members, officers, directors, employees, volunteers, agents or any other representatives of IKA, for any such causes of action, claims, demands, losses, expenses or liability. I understand that conduct by me deemed inconsistent with the rules of sportsmanship and fair play, could result in expulsion from this or any other IKA sponsored activity or program. I have fully read this document, understand its meaning and the legal impact thereof, have had the opportunity to have my/our attorney review this document and explain it to me prior to signing my name below. I voluntarily sign this Waiver, Release, Covenant Not to Sue and Indemnity Agreement. I voluntarily, of my own free will and without distress or coercion sign this waiver, release, covenant not to sue and indemnity agreement.

I understand and agree that a facsimile copy of my signature is just as valid as my original ink signature. If faxing a copy of my signature on the document to the IKA, I agree to mail or otherwise deliver a copy of the original document containing my original ink signature to the IKA within 7 days.

         

  Participant /I f Minor Parent or Guardian signature Date

REGISTRATION AND PAYMENT MUST BE RECEIVED ON OR BEFORE FEBRUARY 27, 2012

Number Attending Qty $ Qty $52 Qty $ Adults (16 years old +)

$45.00 ea Children (under 16 years old)

$25.00 ea TOTAL Student 1 Student 2 Student 3 Student 4 Student 5

Adult (x)

Child (x) Last First M.I.

Address:

Street Address Apartment/Unit #

City State ZIP Code Payment Information: if paying by check please mail to Robert E Robert • 26 Hooker Drive • West Hartford, CT 06107

Check One

Check Payable to IKA LLC

Visa

MC

AMEX

Credit Card Information

Name on Credit Card

Credit Card Number Expiration Date CVV Security Code

CVV is the last 3 digits on the back of your card. For AMEX it's the 4-digit code on the front side.

 

                          

        Return for to:     Robert E. Robert                       26 Hooker Drive                      West Hartford, CT  06107         or email to:    sensei@hokllc.com         or fax to:    860.292.1114