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:________

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.