Release & Registration Form
Open to all styles and ranks.
March 19, 2005
Green McAdoo Community Center
Clinton, Tennessee
*Name________________________________________ Age ________
*Address __________________________________________________
*City _____________________________ State _______ Zip ________
*Phone ______________________ *Email _______________________
Instructor __________________________________________________
I, the undersigned, register myself for a seminar/workshop in martial arts techniques. Which is
sponsored by Gilbert’s Isshin-ryu Karate School, and taught by Mr. John Kerker of Harrill’s
Isshin-ryu Karate School, Inc.
I recognize the possibility of injury inherent in this activity, and I further understand that said
injury might arise from, but not be limited to the instruction, explanation, and/or practice and
training in the subject matter presented at this seminar. I realize that all risk of injury or loss of
any kind is assumed by me and I will hold harmless Mr. John Kerker, Harrill’s Isshin-ryu Karate
School Inc., Gilbert’s Isshin-ryu Karate School, the City of Clinton, Green McAdoo Community
Center, their owners, officers, official instructors, other seminar participants, employees of said
organizations, and their agents for any and all losses and/or injuries sustained by me as a result of
this seminar.
I am in good health and physical condition, and assume all cost of any and all losses and/or
injuries to myself. I agree to conduct myself courteously and obey the rules set forth for training
at this seminar, based on Oriental traditions, common courtesy, and common sense.
Signature ________________________________________________ Date ________________
Parent or Guardian ______________________________________________________________
(Required if under 18 years of age)