ITA Summer Seminar Pre-Registration

Name Name First Middle Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Home Dojo
Please indicate your attendance for Morihiro Saito Shihan 20 Year Memorial Seminar:
(Check Full Weekend OR days that you'll be attending)

Please indicate your attendance for Morihiro Saito Shihan 20 Year Memorial Seminar:
(Check Full Weekend OR days that you'll be attending) Full Weekend (Thurs - Sun) Friday Saturday Sunday
Please indicate your attendance for meals: (Check all that apply)

Please indicate your attendance for meals: (Check all that apply) Friday Lunch ($5) Friday Hajime ($Pay for your own meal) Saturday Party (Banquet catered by Acapulco @Shushinkan $15 or $20)
Would you like to order a T-shirt?
(T-shirts must be pre-ordered to guarantee you'll get one)

Would you like to order a T-shirt?
(T-shirts must be pre-ordered to guarantee you'll get one) Yes No
Please enter the Quantity and Size(s) of T-shirts you'd like to pre-order.
HEALTH INSURANCE INFORMATION
Name of Insurance Provider
Insurance Policy #
EMERGENCY CONTACT INFO
For your safety, please provide us with the best person to contact in the event of an emergency.
Emergency Contact Name Emergency Contact Name First Last
Relationship
Emergency Contact Address Emergency Contact Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Emergency Contact Phone Emergency Contact Phone - ### - ### ####
HOLD HARMLESS AGREEMENT AND WAIVER OF LIABILITY
In consideration of the sponsorship of this Aikido Seminar by Minnesota Aiki Shuren Dojo; And in further consideration of my participation in this Aikido Seminar;
I recognize that the practice of Aikido shares the hazards of any martial art or other strenuous physical activity as well as possible exposure to the COVID-19 coronavirus. I hereby agree to assume ALL risk of injury and loss that may arise as a result of participating in this activity, and further agree to hold: ISD 728, and its agents, Minnesota Aiki Shuren Dojo and its members, as well as Mark Larson, harmless for any injury or loss that arises as a direct or indirect result of any act or omission of any third party.

I hereby release and hold harmless ISD 728, its directors, regents & trustees, agents, and employees, Minnesota Aiki Shuren Dojo and its members, as well as Mark Larson, instructor for above named event, for any personal injuries I may sustain as a result of my participation in the activities associated with this Aikido Seminar.

By signing below, I agree to each statement above and release ISD 728 and it’s agents, Minnesota Aiki Shuren Dojo and its members, and Shihan Mark Larson from any and all liability for any injury or unintentional exposure or harm due to COVID-19.
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ITA Summer Seminar Pre-Registration

HEALTH INSURANCE INFORMATION

EMERGENCY CONTACT INFO

HOLD HARMLESS AGREEMENT AND WAIVER OF LIABILITY