Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

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Date of Birth *

MM

DD

YYYY

Emergency Contact *

First Name

Last Name

Emergency Contact Number *

(###)

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Declaration *

1. In participating in this event, I understand the risk of harm (including personal injury or death, damage to property or economic loss) and are responsible for my own actions and/or involvement 2. I release and waive all liability in respect of this event (or its agents, employees or contractors), that may otherwise have arisen as a result of my participation in the seminar. 3. I understand that this event (or its agents, employees or contacts) will not be liable for the cost of treatment of any injuries that may be sustained as a result of participating. 4. By participating in this event and during this event, I agree that I become a member of AKKA and Matsushima Kyokushin Australia Inc (MKA) for this event only and agree to obey by the rules of the seminar. 5. Photos may be taken during the course of this day. These photographs may be used on official websites, Facebook page or other social media.

I accept

Consent *

The entrant has completed this form or if the applicant is under 18 years of age the application has been submitted by the guardian. By checking this box, the entrant or legal guardian has completed this form and consents to the participant's entry to this event.

I accept

Name of person submitting this form *

First Name

Last Name