J.R. WEST'S HAPKIDO SEMINAR

291 HWY. 51, E-10
RIDGELAND , MS   39157
(601) 856-8487

 FRI, SAT & SUN – February 22, 23 and 24,  2008 

FRI.  6:00 P.M. - 9:00 P.M.
SAT.  9:00 A.M. - 7:15 P.M.
SUN.  10:00 A.M. – 1:00 P.M.

          FEE:  $85 at the door;  $65 Pre-registered by February 9, 2008

Save $20 by Pre-registering!

"Make all checks payable to J.R. West."

[[  OPEN TO ALL BELTS  -  AGE 15 AND ABOVE 15 AND ABOVE   [[

The seminar will be held at: 

Clarion Hotel & Suites Jackson North
Phone: (601) 366-9411     Fax: (601) 366-6688
5075 Interstate Hwy 55 N., Jackson, MS, 39206

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REGISTRATION FORM

NAME ________________________________ PHONE  (__________)________________________

DATE OF BIRTH____________________   Email Address_________________________________

 HOME ADDRESS _________________________________________________________________

  CITY ___________________________ STATE ______________  ZIP___________________

 RANK ____________  STYLE ____________________ INSTRUCTOR _____________________

 SCHOOL NAME ________________________________________________________________

 SCHOOL ADDRESS ___________________________________________________________

  CITY __________________________________   STATE ________  ZIP ___________

 ORGANIZATIONAL AFFILIATION ____________________________________________

RELEASE:   For and in consideration of the use and membership of West's Hapkido Academy, Inc. facilities and other good and valuable considerations allowed by West's Hapkido Academy, Inc., I do hereby for myself, my heirs, executors, administrators, personal representative and/or assigns fully and forever remise, West's Hapkido Academy, Inc. and all other persons, firms, or corporations from any and all claim or claims, demands, injuries, damages, actions, causes of action, suit or suits or anything whatsoever resulting or to result to me by reason of any accident or injury that may occur during my voluntary use of said facilities.

          I do covenant with each and all parties released that I will hold them forever harmless and indemnify them and each of them from any and all claim or claims hereafter presented by any persons, firm, or corporation. I hereby authorize any and all photographs taken at this event to be used in any manner by the USKMAF or West’s HapKiDo Academy Inc.

  I understand that no refunds will be made after February 9, 2008.

 NAME______________________________________DATE_______________________

 PARENT/GUARDIAN SIGNATURE_________________________________________

                                                                 (IF UNDER 18 YEARS OF AGE)