Print and mail this form and appropriate fee to:

Texas Spirit Camp 2005
c/o Brian Duffy's Kenpo Karate
P.O. Box 40009
Austin, TX 78704
ph 512.444.9889 fax 512.444.9928

One Camp Session $80.00	Two Camp Sessions $120.00

Registrant Name_____________________________________________________Date___________________

Address__________________________________________________________

City _______________________________ State/Province__________________

Zip/Postal Code ____________________________________________________

Phone Number _________________________________________

email _________________________________________

Rank __________________________Instructor _________________________________________

I will attend: Sessio#1_____, Session#2_____, Session#3_____, Session#4_____.

I will_____/will not_____ attend the Saturday Night Dinner.

How many?_____Adults, _____Kids.

I (print your name) __________________________, the undersigned, do hereby voluntarily submit my application for participation in the Texas Spirit Camp, and I state that I am physically fit to participate in this event and acknowledge that the fighting aspect of this training involves bodily contact and the existence of personal risk. In consideration for being permitted to participate in the camp, I hereby assume all risk and will indemnify and hold harmless from any liability, actions, causes, debts, claims, and demands of every kind whatever, which I now have, or which may arise, in connection with my participation, the following parties: Brian Duffy; Brian Duffy’s Kenpo Karate; the American Kenpo Federation and the employees and staff of the aforementioned entities as well as the instructors and other participants of this camp.

I give permission for emergency first aid to be rendered in the event of an injury. Should it be determined that further medical attention is required, I give permission to be transported to the closest available medical facility for private and/or emergency medical services/treatment. I also give permission for the administration of any medication and/or procedure deemed necessary by a qualified medical doctor to myself (or to my child until my arrival). I will be solely responsible for all costs of any such medical services/treatment/procedures rendered.

I am allergic to the following medications and have the following conditions which should be considered when treating me for illness or injury:

________________________________________________________________

________________________________________________________________

________________________________________________________________

I give permission for my likeness and image to be used in connection with any commercial or promotional enterprise conducted by the sponsors of this event without any compensation for myself and I release the producers of any such promotional acitivites from any liability, actions, causes, debts, claims, and demands of every kind whatever which I now have, or which may arise, in connection with my participation.

Camp Dates October 7, 8 & 9, 2005.

_______________________________________________________________
Signature and Date

_________________________________________________________________
Signature of Parent or Guardian if under 18 years of age and Date

Questions? Comments? Email Mr. Duffy.
Copyright 1998 Brian Duffy's Kenpo Karate.