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Registration Form_1_


									                   Presenting The Okinawa – Midwest Connection
                                        May 18th – 20th, 2007
                                         Indianapolis, In
                                        Registration Form

Name:_____________________________ Address:______________________________

City:________________ St:___ Zip:__________ Phone:__________________________

Age:_____ Sex:_____ Rank:__________ Sensei:________________________________

School Name & Address:___________________________________________________

Emergency Contact:________________________ Phone:________________________

                                Cash or Money Orders Only
                      Master Card or Visa may be called in on the phone
                                     Camp Fee:$150.00

Please send payment to Eddie B Bethea, Jr., P.O. Box2013, Kokomo In 46902-2013, for
participation in the Shorin ryu Shorinkan Okinawa-Midwest Connection Camp.
I do hereby voluntarily submit my application for participation in this camp, and I do
assume all risks of personal injury (including death) and losses which I may incur by my
participation. Acting for myself, my heirs, and my assignees, I do hereby release the host,
the staff, facility owners, all instructors, and participants connected in any way with this
camp, from any and all liabilities.

Signature:______________________________________ Date:____________________

Parent or Guardian (if under 18 years of age):__________________Date:___________
A $75.00 deposit is required no later than April 15th, 2007. Mastercard or Visa is accepted. Personal
checks will be accepted if you agree to a $30.00 handling fee for returned checks (NSF).

There will be T-Shirts available for sale during the Okinawa – Midwest Connection
Camp. Please indicate the number and sizes that you would like. Cost will be $15.95 or
two for $29.95

XXXL___; XXL___; XL___; L___; M____; S____; Ch-L____

Camp Hotel: Marriott Indianapolis East, Rate - $85 per Night
7202 East 21st Street, Indianapolis, In 46219
Adjacent Hotel: LaQuinta - Rate - $65 per night
7304 E 21st Street , Indianapolis, In
Make Reservations Now!

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