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BlackBeltBlog ---- US JU-Jitsu Federation ---- Schedules

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.


Please complete and following waiver - choose the first for adults or the second for minors.

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

Kwanmukan Main Page


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.