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Grandmaster George E. Anderson, 10 Dan Hanshi, Director
300 Kenmore Blvd, Akron, Ohio 44314
Phone: (330) 753-3114
Fax: (330) 753-6888
Kwanmukan Main Page
Kwanmukan International Black Belt Registration Form
For Accuracy, Please Print Neatly!
You can send this text as body of email, fax, or mail it.
Date _______________
Full Name (not nickname)_____________________________________________________________________
Email Address _____________________________________________________________________
Present Dan grade____________ Applying for Dan grade of ___________________
Discipline: Karate__ Jujitsu__ Kobudo _ Taekwondo __ Kung Fu __Other ________________________________
Shihan's Name _____________________________________________________________________
Club _____________________________________________________________________
Sex_________ Date of Birth ________________ Age______ Country of Citizenship__________________________
Street Address_____________________________________________________________________
City____________________________________________ State __________________ Zip Code_______
Phone (home) __________________________________________Phone (business)___________________________
Personal information necessary for issuing of certification.
Social Security #_____________________________________________________________________
Year and month that martial arts training began _____________________________________________
Occupation _____________________________________________________________________
Obligation form competed or on file _________________________________________________________
Signatures:
Registration Date____________________
Standard fees apply, contact your Shihan or Carol Hofer at Headquarters 330-753-3114 kenmore@raex.com
You can by check, draft, money order, or credit card.
Amateur Athletic Adult Waiver and Release of Liability
In consideration of being allowed to participate in any way in the Kwanmukan athletics/sports program, and related events and activities, the undersigned:
1. Agree that prior to participating, they will inspect the facilities and equipment to be used, and if they believe anything is unsafe, they will immediately advise their coach or supervisor in the Kwanmukan of such condition(s) and refuse to participate.
2. Acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including permanent disability and death, and severe social and economic losses which might result not only from their own actions, inactions or negligence but the actions, inactions or negligence of others, the rules of play, or the condition of the premises or of any equipment used. Further, that there may be other risks not known to us or not reasonably foreseeable at this time.
3. Assume all the foregoing risks and accept personal responsibility for the damages following such injury, permanent disability or death.
4. Release, waive, discharge and covenant not to sue Kwanmukan, its affiliated clubs, regional sports organizations, their respective administrators, directors, agents, coaches, and other employees of the organization, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and leasers of premises used to conduct the event, all of which are hereinafter referred to as "releasees" from any and all liability to each of the undersigned, his or her heirs and next of kin for any and all claims, demands, losses or damages on account of injury including death or damage to property, caused or alleged to be caused in whole or in part by the negligence of the releasee or otherwise,
The undersigned have read the above waiver and release, understand that they have given up substantial rights by signing it and sign it voluntarily.
Printed Name:_________________________________________ Contestants Signature __________________________________ Date __/__/__
Parent/Guardian Signature ________________________________ Date __/__/__
Parent/Guardian must sign if contestant is under the age of 19.
****************************************** Use following form for Minors **************************************
Amateur Athletic Waiver for MINORS and Release of Liability
In consideration of being allowed to participate in any way in the Kwanmukan athletics/sports program, and related events and activities, the undersigned
1. Agree that the parent(s) or legal guardian(s) will instruct the minor participant that prior to participating, he or she should inspect the facilities and equipment to be used, and if the participant believes anything is unsafe, he or she will immediately advise his or her coach or supervisor of such condition(s) and refuse to participate.
2. Acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including permanent disability and death, and severe social and economic losses which might result not only from their own actions, inactions or negligence but the actions, inactions or negligence of others, the rules of play, or the condition of the premises or of any equipment used. Further, that there may be other risks not known to us or not reasonably foreseeable at this time.
3. Assume all the foregoing risks and accept personal responsibility for the damages following such injury, permanent disability or death.
4. Release, waive, discharge and covenant not to sue the Kwanmukan, its affiliated clubs, regional sports organizations, their respective administrators, directors, agents, coaches, and other employees of the organization, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and leasers of premises used to conduct the event, all of which are hereinafter referred to as "releasees" from any and all liability to each of the undersigned, his or her heirs and next of kin for any and all claims, demands, losses or damages on account of injury including death or damage to property, caused or alleged to be caused in whole or in part by the negligence of the releasee or otherwise,
The undersigned have read the above waiver and release, understand that they have given up substantial rights by signing it and sign it voluntarily.
Parent or Guardian Signature ___________________________________________________ (Signature/Relationship) Date ____/____/____
Parent or Guardian Signature ___________________________________________________ (Signature/Relationship) Date ____/____/____
Printed Name of Parent or Guardian:______________________________________________
Printed Name Of Participant:__________________________________________________________________________________________
Address of Participant:_______________________________________________________________________________________________
Institution/Organization:____________________________________________________________
Click here to register your name to receive information from us

Grandmaster George E. Anderson, 10 Dan Hanshi, Director
300 Kenmore Blvd, Akron, Ohio 44314
Phone: (330) 753-3114
Fax: (330) 753-6888
The name Kwanmukan is a registered service mark of the US Jujitsu Federation and is legally protected under the laws of the United States of America. All information published is for personal use only and is protected under international copyright laws. Duplication for personal use of material published here is permitted but use for profit or business is not permitted unless permission is obtained.