HIDY OCHIAI KARATE NOVA
SELF-DEFENSE SEMINAR
Official Registration Form
Hidy Ochiai’s Karate of Northern Virginia
20604 Gordon Park Sqaure #170  Ashburn, VA  20147
571-420-6758
1. Name of participant:___________________________________________________________
(first)
(middle initial)
(last)
2. Address:________________________City:_________________State:___Zip:_____________
3. Phone (best to reach you):________________________Email:_____________________________
4. Date of Birth: ____________________________
5. Any serious disease or injury in the past which my limit your ability to participate fully
in this Hidy Ochiai Karate NOVA Self-defense Seminar?
Yes
No
If so, please explain____________________________________________________
6. How did you hear about this seminar: _____________________________________
7. Have you ever received instruction in karate, judo, or other martial arts?
Yes
No
If so, what style, where and from whom?_____________________________________
In consideration of participation in this self-defense seminar, I agree that I will not abuse the
techniques, energy, and strength but only use them for good and constructive causes. I will act with
a respectful attitude toward others always during the seminar as well as everywhere in daily life. I
will follow the instructor's teaching faithfully and abide by the rules and regulations set by Hidy
Ochiai's school.
I further covenant and agree that by enrollment and participation are voluntary, and I release Hidy
Ochiai Washin-ryu Karate-do of the Mid-Atlantic, LLC, Hidy Ochiai, Ltd., the instructors, students,
and employees from any and all liability and hold them harmless for any loss or injury that I may sustain as a result of my participation in the seminar. I have read and understand this agreement.
Date:___________ Applicant Signature (if 18 yrs. and up): _____________________________________
I affirm that I am the lawful parent or guardian of the above minor child and that I have read
and agree to the above terms and conditions:
Date:___________ Parent/Guardian: _______________________________________________________
(Parent or legal guardian must sign here if the applicant is under 18 years old)