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HAWAIIAN SHOTOKAN KARATE DO

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					                                HAWAIIAN SHOTOKAN KARATE-DO
                                  and Kaito Gakko Judo Jujitsu and Hawaiian Lua
                                     (Pacific Justice and Reconciliation Center)
                                19 North Pauahi Street, Chinatown-Honolulu, 96817

                                     Multi-Purpose Registration Form
Date: _____________

Information Type:         New       Renewal       Changes     Promotion       Special Events   (Circle One)
Name:
____________________________________________________________________________________
Address:
____________________________________________________________________________________
City: _______________________State: ______ Zip: _______ Phone:(___)_______________________

Age: _______ Birthdate: ____/___/____ Sex: ______email address:_____________________________
Your School/Dojo Name: _______________________________________________________________
Your Current (or last ) instructor : ____________________________________ (Enter “NONE” if none)
Your Current Rank : _______________ Belt Color: ___________               Date Promoted:____/____/____

Registration, Dues & Fees, or Special Events Registration and Costs:
Yearly Dues/Fees (includes insurance)                   Diploma Fees (certificate and records)
All Kyu Ranks       $ 15.00____                         All Kyu Ranks              $ 5.00_____
Black Belts         $ 20.00____                         Black Belts 1 thru 5       $ 30.00_____
Chief Instructors   $ 25.00____                         Black Belts 6 thru 10      $ 50.00_____
Dojo Registration   $ 25.00____                         (Belts not included)
Monthly Dues/Fees                                       Hookupaa Na Keiki
Individual (child or adult)       $ 45.00 ____          Black T Activities Shirt       $ 15.00 _____
Additional Family Member          $ 25.00 ____          White Ceremonial Kihei         $ 5.00 _____
Macho/Century Gi Uniform                                SPECIAL EVENTS
Gi Uniform and White Belt $30.00 _____                  Event Name & Cost:__________________ _____
Or available at:
Hawaii Martial Arts Supply, Maunakea Street Honolulu    Additional Event/Seminar: ___________________ _______
KC Martial Arts, Kamehameha Highway
                                                        Meal/Banquet Name & Costs: ________________ ______

                                                        Meal/Banquet Name & Costs: ________________ ______

                                                        Other–Description and Costs:_________________ ______


Please place a check mark next to all items which apply:                      Total Amount $ ___________


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HAWAIIAN SHOTOKAN KARATE-DO
Kaito Gakko Judo Jujitsu and Hawaiian Lua
Pacific Justice and Reconciliation Center

Waiver of Liability (Pacific Justice and Reconciliation Center)
I certify that I am medically and physically able to participate in this activity. I have been made
aware of the potential hazards involved in karate, judo, jujitsu, and Hawaiian Lua, and other
self defense training, seminars, and competition. Knowing the potential hazards involved and in
consideration of my application being accepted, I hereby for myself, my heirs, executors,
administrators or anyone else who might claim on my behalf, covenant not to sue, waive, release
and discharge the Pacific Justice and Reconciliation Center, Hawaii Shotokan Karate-Do, Kaito
Gakko Judo Jujitsu and Hawaiian Lua, Peace Through Martial Arts, Hookupaa Na Keiki, it’s
instructors, and associates, the City and County of Honolulu, the State of Hawaii, and anyone
acting on their behalf, from any and all claims of liability for personal injury or death arising
out of, or in the course of participating in this activity. This release and waiver extends to all
claims of every kind or nature whatsoever, foreseen or unforeseen, known or unknown.

Your Signature: _________________________________________________Date: ____/____/____

Parental Consent if Under 18 :
______________________________________________________________ Date: ____/____/____

Print Parent’s Name:
_____________________________________________________________Phone: ________________

                                                                   Cell Phone: ________________

                                                                      E Mail: _________________

Name of Emergency Contact:
____________________________________________________________ Phone: _________________

                                                                   Cell Phone: _________________

                                                                      E Mail: _________________

Mail this form to: PJRC - Hawaiian Shotokan
19 North Pauahi Street
Chinatown, Honolulu, HI 96817

Please make all checks and money orders to PJRC – Hawaiian Shotokan;
and attach to this registration form. Mahalo Nui Loa!

Any questions or for assistance please contact:   Dr. Haaheo Guanson 808 330-3771
                                                  pjrcgo@gmail.com
                                                  peacemartialarts@gmail.com

				
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posted:6/29/2012
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