________________________________________________________________________________________________________

(Name)(Age)(Phone number)                    (e-mail address)

________________________________________________________________________________________________________

(Street address)(Apartment or P. O. Box number)

________________________________________________________________________________________________________

(City)(State)(Zip code)

NOTE: Regular fee, $249. If received before June 1, pay only $229 for instruction. All participants must complete the application form and sign the waiver.

For office use only: ________DP________BAL________G5-9________G10+

________ Pay only $99 non-refundable deposit. The balance of $130 is due at check-in. Kids Camp members ages 6-12 years pay a balance of only $100.

________ I am an agent of AIKIA. My agent identification number is _______________.

________ I am a member of a group of five or more participants. To qualify for group rates, a single leader must collect all applications and fees to be mailed in one package.

Group Leader: _____________________________________________________

________ I missed the June 1, 2010, deadline. Enclosed is my $99 deposit. I will pay the balance of $160 at check-in.

Note: Confirmation letters will be mailed/e-mailed to all pre-registered campers during the first week of June. Please make all checks/money orders payable to: Karate College 2010. Mail applications and fees to: Karate College, P. O. Box 402, Christiansburg VA  24068. For more information, call (540) 381-2025.

Waiver

I have had previous martial arts instruction, and I understand that practice in the Karate College 2010 (June 24-27) may be dangerous and that, by participating in this program, I may be seriously injured. I freely waive all rights to Dr. Jerry Beasley, the instructors, and staff of Karate College 2010, and to Radford Recreation Center. I have accident and/or medical insurance to cover any injury that I might sustain; therefore, in return for admission to the camp, I forever give up any rights against Dr. Jerry Beasley, Radford Recreation Center, Radford University, and Karate College 2010 promoters, instructors, and staff. My signature is proof of my intention and understanding of this policy.

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(Signature of participant)(Age)(Date)

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(Name of parent or legal guardian if participant is under age 18 years)

_______________________________________________________________________________________________

(Signature of parent or guardian)(Date)

www.AIKIA.net

Dr. Jerry Beasley

P.O. Box 402

Christiansburg, VA 24068

June 24-27, 2010

Co-sponsored by Century Martial Arts