Mikes Ryukyu Kempo Karate and Kobudo Self-Defense Seminar Registration Form

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Dojo Name:HIDE FROM VIEW

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Dojo Email:HIDE FROM VIEW

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Seminar Date Helper:HIDE FROM VIEW

Date

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Seminar Date Name:HIDE FROM VIEW

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Seminar Time:HIDE FROM VIEW

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Last Date To Pay:HIDE FROM VIEW

Date

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Must be at least 18 years old to complete this form. Please note that Annual School Members are already registered upon enrollment and should not fill out this form. If you are an Annual School Member and wish to purchase admission, you can do so by logging into our EzPay platform and navigating to Student Tickets and Event Registration. If you require any assistance, please feel free to contact our Dojo Head at (803) 646-0638 or email our team at dojohall@hotmail.com.

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How many will be participating?* This field is required.Include General Guests and Students who are NOT Annual School Members. Do Not include Annual School Members.

Max 5. Contact our dojo for special registration & purchasing information for participants exceeding our 5 max limit.

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You have selected a number that exceeds our 5 max. limit for this registration.

Contact our Dojo for special registration and purchasing information.

Email: dojohall@hotmail.com
Request a call back from our Dojo Head at (803) 646-0638.

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Primary Participant's Name* This field is required.

First Name

Last Name

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Primary Participant's Birth Date* This field is required.Due to the mature content of this event, all participants must be at least 8 years old or older to participate.

mm-dd-yyyy

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Participant 2's Name* This field is required.

First Name

Last Name

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Participant 2's Birth Date* This field is required.Due to the mature content of this event, all participants must be at least 8 years old or older to participate.

mm-dd-yyyy

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Participant 3's Name* This field is required.

First Name

Last Name

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Participant 3's Birth Date* This field is required.Due to the mature content of this event, all participants must be at least 8 years old or older to participate.

mm-dd-yyyy

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Participant 4's Name* This field is required.

First Name

Last Name

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Participant 4's Birth Date* This field is required.Due to the mature content of this event, all participants must be at least 8 years old or older to participate.

mm-dd-yyyy

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Participant 5's Name* This field is required.

First Name

Last Name

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Participant 5's Birth Date* This field is required.Due to the mature content of this event, all participants must be at least 8 years old or older to participate.

mm-dd-yyyy

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You selected a participant is currently enrolled in Mike's Ryukyu Kempo Karate & Kobudo™ Annual School Membership and Recognition Services. Next, you will be asked to enter the participant's Student ID Number to unlock an exclusive DISCOUNT CODE for 20% OFF ALL Annual School Member Admissions during checkout.The 5-digit Student ID Number is found on the front of a Student's Student Card below the large Bar Code.

The 5 digit Student ID Number can be found on the front of your Student ID Card below the large Bar Code.

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Enter a participant's Student ID Number.* This field is required.Note: Upon submission, our office will verify enrollment. If the Student ID Number is NOT valid, we will remove the discount and bill you for the remaining amount.

The 5-digit Student ID Number is found on the front of a Student's Student Card below the large Bar Code.

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We found you! Welcome to our event.

Please select NEXT to continue.

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Primary Email Address* This field is required.

example@example.com

Confirm Email

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Primary Contact's Name* This field is required.

First Name

Last Name

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Primary Contact's Phone Device* This field is required.A "Mobile" Phone Number is our dojo's fastest and most preferred way to communicate with you. Please enter "Cell" as a first choice, followed by a "Cell Number" on the next screen. If no such device exists, select another choice from the drop-down box below.

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Primary Contact's Phone Number* This field is required.

Add a good phone number in case our office needs to contact you.

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Do you wish to add an Emergency Phone Number?

YESNO

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Emergency Phone NumberSelect "NEXT" to skip this question.

Add a good phone number to contact in case of an emergency.

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Would you like to receive an information packet about our weekly classes?* This field is required.Get information about Mike's Ryukyu Kempo Karate & Kobudo™, including class schedule and prices, by mail, email, phone, or text. Standard message and data rates may apply.

YESNO

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Health Warning* This field is required.Must be at least 18 years old to answer.

This seminar may involve light to moderate joint manipulation and striking techniques to practice the effectiveness of each application being taught while, at times, repeatedly being taken down to the ground. Please consider if you or your child is physically fit to take this prescribed course of instruction and do so of their own free will.

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Carefully go through each statement and indicate that you understand each one.* This field is required.These statements are necessary for our dojo to conduct business and cannot function properly without such provisions. Your acknowledgment and authorization are required for ALL SEVEN statements.

I understand Mike's Ryukyu Kempo Karate & Kobudo may send important school information, notices, and updates via text messages and/or emails. Message and data rates may apply.

I understand that Mike's Ryukyu Kempo Karate & Kobudo is an independent and private organization on private property and reserves the right to terminate enrollment or the dismissal from the school property of any participant and/or their guest at any time. I acknowledge that disorderly conduct is not allowed, and if I or my child engage in such activities, we may be dismissed from the school.

I acknowledge that Mike's Ryukyu Kempo Karate & Kobudo and the property owners are not responsible for and hold harmless from any and all liabilities, damages, losses, and costs incurred or arising from the conduct or activity of its participants and/or visitors.

I further agree that I or my child enter this instruction course freely and voluntarily. Mike's Ryukyu Kempo Karate & Kobudo has made no express or implied warranties or guarantees to induce me or my child to enter into this agreement.

I understand in the event of an injury or medical emergency, Mike's Ryukyu Kempo Karate & Kobudo may provide first aid, arrange transport to a medical facility, and/or authorize emergency treatment as recommended by a doctor or a trained medical professional for me or my child at my cost. I understand that all reasonable efforts will be made to contact me about my child or my emergency contacts if I am the participant in case of an injury or medical emergency.

I understand that Mike's Ryukyu Kempo Karate & Kobudo cannot guarantee that I or my child will not become infected with viruses or any contagious sickness.

I agree that my child or I will not attend any event at any time when my child or I believe that they might be ill, are experiencing any symptoms of illness, or have been exposed to a person or persons known to be infected with a contagious illness.

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Do you need assistance to initial or sign your acknowledgment, authorization, and waiver for all provisions in this registration?* This field is required.Users with impairments may have trouble using a mouse to draw their initials or signature. Those users may choose to TYPE their initials and signature instead of drawing them.

YESNO

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Guardian or Adult Participant's Initials* This field is required.I UNDERSTAND AND ACCEPT THAT MY ELECTRONIC INITIALS WILL BE AS VALID AS HANDWRITTEN INITIALS AND CONSIDERED ORIGINAL TO THE EXTENT ALLOWED BY APPLICABLE LAW.

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Guardian or Adult Participant's Initials* This field is required.I UNDERSTAND AND ACCEPT THAT MY ELECTRONIC INITIALS WILL BE AS VALID AS HANDWRITTEN INITIALS AND CONSIDERED ORIGINAL TO THE EXTENT ALLOWED BY APPLICABLE LAW.

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GENERAL WAIVER OF LIABILITY

In consideration for my or my child's attendance and participation in the martial arts training offered by Mike’s Ryukyu Kempo Karate & Kobudo and the products sold by Mike’s Ryukyu Kempo Karate & Kobudo, I acknowledge the existence of certain inherent risks in this type of training and usage and hereby agree to assume all risks. I or any personal representatives further forever relieve Mike’s Ryukyu Kempo Karate & Kobudo, the school, its management, property owners, assigned staff, fellow participants, visitors, their families, or other representatives from liability resulting from bodily injury (partial and/or total disability), paralysis, viruses, any type of contagious sickness, death, or loss, whether personal belongings or bodily injury.

I agree that my child or I will not attend any event at any time when my child or I believe that they might be ill, are experiencing any symptoms of illness, or have been exposed to a person or persons known to be infected with a contagious illness.

I also hereby state that I or my child is physically fit to take the prescribed course of instruction and do so of my own free will.

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General Waiver Acknowledgment* This field is required.Must be at least 18 years old to answer.

I HAVE CAREFULLY READ AND FULLY UNDERSTAND ALL PROVISIONS OF THIS GENERAL RELEASE, AND FREELY AND KNOWINGLY ASSUME THE RISK AND FOREVER WAIVE MY RIGHTS CONCERNING LIABILITY AS DESCRIBED WITHIN THE GENERAL WAIVER OF LIABILITY.

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Guardian or Adult Participant's Name* This field is required.Do not include PERIODS (".") in the "Prefix" or "Suffix" fields if required.

Prefix (Optional)

First Name

Middle Name

Last Name

Suffix (Optional)

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Guardian or Adult Participant's Signature* This field is required.I UNDERSTAND AND ACCEPT THAT MY ELECTRONIC SIGNATURE WILL BE AS VALID AS A HANDWRITTEN SIGNATURE AND CONSIDERED ORIGINAL TO THE EXTENT ALLOWED BY APPLICABLE LAW.

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Guardian or Adult Participant's Signature* This field is required.I UNDERSTAND AND ACCEPT THAT MY ELECTRONIC SIGNATURE WILL BE AS VALID AS A HANDWRITTEN SIGNATURE AND CONSIDERED ORIGINAL TO THE EXTENT ALLOWED BY APPLICABLE LAW.

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Signee's Email VerificationType your email address below and select the "Send Verification Code". Afterwhich, you will receive an email verification code from JotForm with "Email Verification Code Regarding Mikes Ryukyu Kempo Karate and Kobudo Self-Defense Seminar Registration Form" in the subject line. If you do not see this email, please check your spam or junk mail filters. Follow the instructions provided.

example@example.com

Email Verified

The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification

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Signature Date/Time Stamp* This field is required.

Date

Hour

Minutes

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Please verify that you are human.* This field is required.Used for SPAM Protection.