Seminar Registration Form
(Please Print Or Type)

Name:(Last)___________________________ First:___________________ M Initial:_____

Address(Street):___________________________________ City:_____________________

State:_________ Zip Code:__________________ Country:__________________________

Date Of Birth: Month_____ Day_____ Year_________ Phone: (______)________________

Style And Rank:_________________ Date Of Rank: Month_____ Day_____ Year:________

I hereby submit my application for participation in this Martial Arts Seminar. I clearly recognize that a risk is involved in participating in this seminar and related activities, which has been completely explained to me and my parents and/or guardians. Participant attests that he/she is physically fit to participate in the seminar(s).

In consideration thereof, I hereby waive, release, and forever discharge the ITA, ITA Institute, Grandmaster James S. Benko, the seminar host(s), and all participants, on behalf of myself, my heirs, my executors, my administrators and assigns, of any and all claims, rights, or causes of action whatsoever for any damages or injuries which may arise traveling to, participating in, returning from the seminar(s), or which might arise thereafter, against any person or entity in any way connected with the seminar. The parents and/or guardians of the applicant hereby request that this application be accepted, and in consideration thereof, agree to indemnify and release all members of the ITA, ITA Institute, Grandmaster James S. Benko, seminar participants and seminar host(s), from all claims made or which may be made on behalf of the applicant, for the aforesaid consideration. I understand that all fees are non-refundable.

I hereby agree that any photographs and/or videos taken of me during my participation in this seminar may be used for publicity or any other use seen fit by the ITA, ITA Institute, ITA Publications, and Grandmaster James S. Benko, without any compensation to my parents, guardians, or myself. I hereby waive any right I may have to inspect and/or approve any photographs and/or videos of myself.

        _______________________________________     __________________________
                                           Applicant's Signature                                                                   Date

        _______________________________________     __________________________
                           Signature of parent or guardian if applicant                                                 Date
                                         is under 18 years of age.

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