Mid-America Karate, Inc. Greer Golden, Chief Instructor Martin Vaughan, Assistant Instructor

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: [email protected]
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
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Saturday, December 13, 2014
Willis Intermediate School
74 West William Street
Delaware, Ohio 43015
11:30 AM (Gym opens at 11:00)
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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.
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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: [email protected]
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