Mini-Camp Shotokan 2009

Online Registration
General Information and Training Schedule

September 25-27, 2009
Register on-line TODAY - classes fill quickly!
Each person must fill out an individual application!

This is NOT an online GROUP registration form. To enroll a group, call us! 706-769-3730
FAX: Print out this web page and fax your registration information to: 706-769-4670

Late Registration Begins September 14, 2009; Additional $10 Late Fee Will Automatically Be Added After 9/14/09

Note: Fields must be filled in completely in order for your registration to process correctly.

 Registration Process
Select your options below:
1 - Complete the camp attendee information.
2 - Select the "SUBMIT Form" button below.
Applicant's Name
 First name

Last name

Declare legal status:
1 - Are You A Member of the AJKA-I, GKA, or ASKA?
Non-members are welcome to attend, simply select "I am not a member".
Camp Session Options

General Information
and Training Schedule

NOTE: Late registration fee of
$10 will be automatically added
after September 14, 2009.

You can also fax your
registration information to:
706-769-4670

NOTE: One person per registration;
each person must fill out
an individual camp registration application.

Rates - Select Sessions to Attend
ONLY Members pick from within this box!
AJKA-I, GKA, and ASKA Member Rates - Select One

2 - Non-member Rates - Select Sessions to Attend
Non-members are welcome to attend!
ONLY NON-members pick from within this box!
Airport Transportation and Host Home Lodging Request:

Will you need to be picked up and dropped off from the Atlanta Airport? It will cost only $7 per person round trip (it's 76 miles one way to the dojo from the Atlanta airport)!

NOTE: Pick-up will be on Friday, Sept., 25, 2009 and you must arrive no later than 2:15 pm, the vans will depart from the bagage claim to the dojo at 3:00 pm SHARP!

Drop-off at the Atlanta airport will be on Sunday, Sept. 27, 2009. The vans will depart the dojo at 12 noon sharp! Plan to arrive at the airport no earlier than 1:30 pm! Book your flights accordingly!

Required - Do you need transportation to and from the Atlanta airport?

Required - Confirm transportation cost:
($7 per person - ROUND TRIP - it's a bargain)

Required - Do you need a host home for lodging on September 25 - 27, 2009?
FREE - first come first serve. You will be put up in host homes near the dojo. Once space is gone, you'll need to make your owe lodging arrangements!
Parent or Legal Guardians Name
NOTE: A minor must have a parent or legal guardian agree to the waiver and release from liability and assumption of risk to attend Mini-Camp Shotokan 2009.
 Skip this section if you're 18 or older:
Parent or legal guardians first name

Parent or legal guardians last name
Are you the parent or legal guardian (you must pick one)?
Applicant's Birthday
Applicants Age
Rank or Dan Level and Organization
 Rank or Dan Level

Organization
Contact E-mail Address
Home Mailing Address
City
State/Province
Zip/Postal Code
Home Telephone - REQUIRED
(include area code)
Cell Phone
(include area code)
Dojo Name
Instructor's Name
Payment Method
(you must pick one)

BILLING INFO
We accept VISA or MasterCard ONLY (Credit or Visa-Debit Cards ONLY):

Enter Credit or Debit Card
Account Number

Account Number

3 Digit Code From the Back of Your Credit Card:

 Card Verification - 3 Digit Code

What is a credit or debit verification number?
Credit or Debit Card Expiration Date (example: 05/09)
 Expiration Date (example: 05/09)
Name of Financial Institution
i.e. - Bank of America, Chase, FirstCard:
 Name of Financial Institution
Account Holder's Name:

First name

Last name
Billing Address
City
State/Province
Zip/Postal Code
Waiver and Release from Liability, Assumption of Risk,
and Enrollment Terms		 The undersigned understands and agrees that the class/course/camp/seminar for which he/she is registering for involves an inherent risk of accidental physical harm or injury and understands that this assumed risk may arise from, but not limited to, the instruction, explanation, practice, and training in the subject matter. The undersigned, therefore, agrees that the risk of any such injury is assumed by him/her, and hereby relieves and agrees to hold harmless, on account of physical and/or mental injury sustained by him/her, the Georgia Karate Academy, Inc., and/or David Gómez, and/or Rebecca Blaze Gómez, and/or American JKA Karate Association-International, aka AJKAI, its owners, officials, instructors, other participants, sponsors, agents, and/or employees from any and all claims, demands, rights and causes of action whatsoever (of all listed individuals or businesses), arising from and by reason of his/her participation in said class/course/camp/seminar. The undersigned further states that he/she is in good health and physical condition and has medical insurance which covers his/her participation in this class/course/camp/seminar. Also, the undersigned agrees to allow, without compensation, the unrestricted use of any photographs, film, or video/DVD recorded material while enrolled at Mini-Camp Shotokan 2009.

Camp fees will be collected as stated above without credit or refund, and is non-transferable.

The undersigned further states that he/she has read this Waiver and Release from Liability, Assumption of Risk, and Camp Participation Terms, understands the contents thereof and has executed same of his/her own free will for him/herself and/or the camp attendee listed above.

You must acknowledge the terms.

First name

Last name
How did you
hear about us?
(required)
Comments
(optional)

Make sure you have selected how many sessions you plan to attend from above BEFORE pressing the "Submit Form" button!

Return to
Georgia Karate Academy, Inc.
American JKA Karate Association - International
Recommended Books and DVD's Perfect Form, Inc. Shotokan DVD's and Books

Minicamp Shotokan 2009 Contact Information
Fax: 706-769-3730 • dgomez@georgiakarateacademy.com

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