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									  Seminar Waiver & Release of Liability
                                                             Long Island Shotokan           Master Seminar
In consideration of being permitted to participate in
any way in the Long Island Shotokan Karate-Do                       SKIF-NY                         Featuring:
karate training or any related activities, I the
undersigned agree (1) That prior to participating I
                                                                                           Hiroyasu Fujishima
have been or the minor below has been examined by
a physician and have been medically released in good
                                                                         Presents:               Hanshi
health to participate in all activities; (2) That prior to
participating I will inspect the facility and equipment
                                                                                           8th Dan SKIF-USA
to be used and, if I believe that anything is unsafe will
immediately advise the person in charge and refuse to
participate. (3) Acknowledge that all participants
                                                               Hiroyasu Fujishima
will be engaging in activities that involve risk of
serious injury, including permanent disability, death,
and severe social and economic losses which might
result not only from my own actions, inactions, or
from the negligence of others, the training methods or
the condition of the premises or of any equipment
used. There may be other risks not known to me or
not reasonably foreseeable at this time. (4) Assume
all the foregoing risks and accept personal
responsibility for the damages following such injury,
permanent disability or death. (5) Release, waive,
discharge, and agree not to sue Long Island
Shotokan Karate-Do, any other instructors or
helpers or others participating in any activities.

Date              ________________


                                                                                                     Hosted by:
Parents                                                          Long Island Shotokan           Long Island Shotokan
Signature___________________________                                 130 Jericho Tkp.              130 Jericho Tpke.
(under 18)                                                        Floral Park, New York      Floral Park, New York 11001
                                                                  Phone:(516) 488-7382           Phone (516) 488-7382
                                                                    Fax:(516) 488-7383            Fax (516)488-7383

                                                                                          Friday, Saturday & Sunday
                                                                                            Jan.14 15&16, 2011
         Schedule & Fees                           Location & Directions                                      SKIF Master Seminar
  Friday Jan.14         Friday Jan.14
   4:00-4:45PM          7:00 – 8:30pm
                                                                                                              Jan. 14,15 & 16, 2011
   Special Needs        Adults/All levels          Long Island Shotokan
                                                      130 Jericho Tpke                               Name:
    5:00-6:00PM                                 Floral Park New York 11001
 Kids all ages/Levels
                                                       (516) 488-7382                                Address
    Sat. Jan.15         Sat. Afternoon
  10:00-11:30AM          1:00-2:30PM        From the west: Take the Cross Island Pkwy. to
 Kids All ages/levels   Adults all levels   Jericho Turnpike East(route 25E). Continue east on
                        Children Green      Jericho Tpke. for about 1 mile. Dojo is located on the
                                            south side of the street.Go to Van Buren avenue
                            and up                                                                   State                Zip
                                            (Gasperini’s Pizza on corner.
    Sun.Jan.16             Sun. Jan.16
     11:00-12:30        BLACK BELT          From the East:Take Jericho Turnpike (route 25)
   Brown & Black         GRADING            To Little Neck Parkway, make U-turn around
        Belts            Immedately         On Jericho Tpk. to Van Buren avenue
                          following                                                                  Phone
                                            Airport : You can fly into either La Guardia or
                                            JFK airport. The Dojo is located about 20
                                            minutes from either one.                                 D.O.B.
                Children                    “Quality Inn Express” located at 256-15
          5 TO 12 YEARS OLD
                                            Jericho Tkp. Floral Park, NY, 11001
                                            (516)718-343-9600                                        Dojo
      1 Seminar             $35.00
     ALL CLASSES           $65.00
                                             “Holiday Inn ” Located at 369 Old Country
                                            Road, Westbury , NY, 11514.                              Rank _____________________________
                                            1-888-890-0242 or Front Desk 1 516 977-5000
           Teens & Adults                                                                                          Please Check
                                                                                                      Fri. 4:00-4:45PM Speical Needs
      1 Seminar             $60.00                                                                    Fri. 5:00-6:00PM Kids all ages/levels
                                                Black Belt Grading Requirements
                                                                                                      Fri. 7:00-8:30PM Adults/All Levels
   ALL CLASSES             $110.00             Minimum 2 seminar classes attended                     Sat.10:00-11.30AM Kids All agaes/levels
                                            **SKIF Membership card, SKIF passbook,                    Sat. 1:00-2:30PM Adults all levels
                                               SKIF application in triplicate, and                             Children Green and UP
   Please pre-register by Jan.5, 2011         $100.00 grading fee. All submitted 2                    Sun.11:12:30PM       Bllk & Brn. Belts.
   Late registration after Jan. 5 , add            weeks prior to grading.                             BLACK BELT GRADING immedately
                 $15.00                              NO EXCEPTIONS                                     following
                                                                                                      Sat Dinner Reservations
**Certified check, money order, cash,
                                                                                                     Deadline for dinner is Jan.10,2011
 American Express, Visa/Master card .
                                                                                                     Payment Enclosed $
     Please make all checks out to:
Long Island Shotokan

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