(Name) (Age) (Phone number) (e-mail address)
(Street address) (Apartment or P. O. Box number)
(City) (State) (Zip code)
NOTE: Regular fee, $269.
If received before June 1, pay only $217 for instruction. All participants must complete the application form and sign the waiver.
________ Pay only $99 non-refundable deposit. The balance of $120 is due at check-in. Kids camp members ages 6-12 years pay a balance of only $100.
________ I am a member of a Black Belt Recruiter group of five or more participants.
Recruiter’s name _________________________________________________ (Must list all participants on one page with payments)
________ I missed the June 1, 2015, deadline. Enclosed is my $99 deposit. I will pay the balance of $165 at check-in.
Lodging: After March 1, 2017 contact the RU conference center for lodging only at (540) 831-5800. E-mail email@example.com or mail to Summer Conference, P.O. Box 6911 RU, Radford VA 24142. RU rates for Karate College are $26 (+tax) for double occupancy and $36 (+tax for single occupancy. Within 1 mile of camp try: Radford Best Western Inn at $79 per night (540)639-3000; The Super 8 @ $69.95 per night (540) 731-9355. Ask for karate College discount.
Note: Confirmation letters will be mailed/e-mailed to all pre-registered campers during the first week of June. Please make all checks/money orders payable to: Karate College 2015. Mail applications and fees to: Karate College, P. O. Box 402, Christiansburg VA 24068. For more information, call (540) 381-2025.
I have had previous martial arts instruction, and I understand that practice in the Karate College 2017 (June 22-25) may be dangerous and that, by participating in this program, I may be seriously injured. I freely waive all rights to Aikia LLC, Dr. Jerry Beasley, the instructors, and staff of Karate College 2017, and to Radford Recreation Center. ______________(initials). I have accident and/or medical insurance to cover any injury that I might sustain;___________(initials) therefore, in return for admission to the camp, I forever give up any rights against Aikia, LLC, Dr. Jerry Beasley, Radford Recreation Center, Radford University, and Karate College 2017 promoters, instructors, and staff. My signature is proof of my intention and understanding of this policy.
(Signature of participant) (Age) (Date)
(Name of parent or legal guardian if participant is under age 18 years)
(Signature of parent or guardian)(Date)
Dr. Jerry Beasley
P.O. Box 402
Christiansburg, VA 24068
Karate College 30
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