November 6-7, 1999 at (or near) the Virginia Ki Society Dojo in Merrifield, Virginia

(Please type or print, and use a separate form for each attendee)

Last Name:_______________________ First Name: ________________________ Middle Initial: _____

Dojo: ___________________________ Rank: _____________________________ Sex: ( F / M )

Mailing address:

Street: ______________________________________________________________ Apt #: ___________

City: ___________________________ State/Province: ___________________ ZIP/Postal code: _______

Country: ______________________________

E-mail address: _________________________________ Telephone (optional): _____________________

Fee enclosed: (please check one)

Please make payments payable to VIRGINIA KI SOCIETY, and mail to:

I understand that I undertake this seminar at my own risk and hereby release the Virginia Ki Society, and all others involved in holding this seminar, from liability should I injure myself. (Parental signature required for participants under age 18).

Signature: _________________________________________________ Date: ______________________

Emergency Contact: _________________________________________ Telephone: _________________

T-Shirt size (circle one): NONE S M L XL 2XL I8TOKYO

(NOTE: T-shirt not included with registration, we’re just trying to get a size-distribution, and desire estimate for ordering purposes)