Mid-America Karate, Inc. Greer Golden, Chief Instructor Martin Vaughan, Assistant Instructor James M. Nelson, Executive Director 1258 Crystal Pointe Cir., Fenton, MI 48430-2051 PHONE 810-354-8554 FAX 810-354-8556 CELL 810-252-7696 E-Mail: MidAmericaRegion@aol.com http:/midamericaiskf.com CLINIC - INSTRUCTOR TRAINING - DAN EXAM Hosted by Mid-America Karate, Inc. Featuring Master Yutaka Yaguchi 9th Dan Chairman of the ISKF Technical Committee ************************************************************************************ Saturday, December 13, 2014 Willis Intermediate School 74 West William Street Delaware, Ohio 43015 11:30 AM (Gym opens at 11:00) ************************************************************************************ Clinic: $40.00* College Students: $20.00* Instructor Training: $20.00 All Dan Exam Registration forms must be postmarked by December 3, 2014 Shodan-$180.00 Nidan-$230.00 Sandan-$295.00 Yondan-$380.00 You must be approved (pretested or retesting) before taking Dan Exam *Register for the clinic early and receive a $5.00 discount (ISKF Members only). Early clinic registrations & payments must be postmarked by: Wednesday, December 3, 2014. Complete the registration form and send it along with the applicable fees to: Mid-America Karate, Inc. 1258 Crystal Pointe Cir. Fenton, MI 48430-2051 Those taking the Dan Exam must also complete a Request for Dan Exam Registration form (typed). This may be downloaded from: www.iskf.com/information You must also enclose one passport size photo. All Dan Candidates must have a mouth guard and hand protectors, if doing kumite. Regular Clinic fees and Instructor Training fees may be paid at the door. ************************************************************************************ All ranks are encouraged to attend this training! If there is inclement weather, please contact your dojo’s instructor or Jim Nelson at: 810-354-8554 (Home) or 810-252-7696 (Cell) Mid-America Karate, Inc. Greer Golden, Chief Instructor Martin Vaughan, Assistant Instructor James M. Nelson, Executive Director 1258 Crystal Pointe Cir., Fenton, MI 48430-2051 PHONE 810-354-8554 FAX 810-354-8556 CELL 810-252-7696 E-Mail: MidAmericaRegion@aol.com http:/midamericaiskf.com Name________________________________________________Current Rank__________________________ MA/ISKF Membership No______________________ Club_________________Date of Expiration__________ E-mail sign-up (Please Print): Applicable fees enclosed: (Make checks payable to Mid-America Karate, Inc.) Clinic, Instructor Training, and Dan Exam Registration Form Amount Paid Clinic / Collegiate $40.00 / $20.00 Instructor Training $20.00 Dan Exam Only Shodan Exam $180.00 Tokui Kata (Individual Kata below) Nidan Exam $230.00 Kata: Sandan Exam $295.00 Age: Yondan Exam $380.00 Height: ISKF Dues $40.00 Start Date: Other Varies Date of Last Exam: Early Clinic Registration* -$5.00 * ISKF Members Only Instructors Signature (below) Total Enclosed How Paid (Mark those which apply): Cash Check Grant Scholarship PayPal ALL Dan registration forms must be postmarked by Wednesday, December 3, 2014 RELEASE FORM The undersigned, in consideration of being permitted to participate in Shotokan Karate training, competition, and/or testing, hereby waives and releases the International Shotokan Karate Federation and its successors, Mid-America Karate, Inc., its members, instructors, affiliates, and facility providers from any liability for damages due to the loss or damage to property, personal injury, or death which may occur at such facility for said purpose. The undersigned represents that he/she is fully aware of the risks of such participation, has no health conditions presenting any increased risk, and has adequate insurance coverage in force to cover any such loss or damage. This release is binding upon the undersigned and his/her heirs, executors, and administrators. ___________________ Date ______________________________________________________ Signature of participant or parent/guardian for under 18