You must bring or mail this form to the Napa Taekwondo Academy: 3216 Jefferson Street, Napa, 94558 --- or E-mail to Terrybrule@aol.com. Questions? Call Terry Brule at (707) 226-5869. For Ages 18 and Up. Seminar Fee is $15.00 per participant, made payable to: "Napa TKD"

Name: _________________________________________________________ Date of birth: __________

Address: ________________________________________________________ Phone #: _____________

E-mail Address: ____________________________________________________


If you know the date and time of an established-class time, put that information in the space below. If you have not expressed interest in a class, you must contact the Napa Taekwondo Academy to obtain information on when the next seminar will take place.

Date: _______________________________ Time: _______________________

Have you ever been convicted of any crimes involving violence or illegal drugs?

If yes, please explain: _______________________________________________


Do you have any physical limitations that may limit your participation: Yes/No ____

If "yes" please explain _______________________________________________

Do you have any children between the ages of 14 and 18 who will be attending the class with you?

Name: _______________________________________ Date of birth: __________

(Due to some mature themes in the presentation, this class is not appropriate for children 13 years and younger. Anyone under 18 must be accompanied by an adult. Childcare will not be provided and participants must arrange for their own childcare).

I understand the nature of the offered seminar and that, by participating, there is a risk of injury to myself or others. By signing this Agreement I agree to indemnify, defend, and hold harmless the Napa Taekwondo Academy, its instructors, agents, and students from and against any claim of injury to person or property arising out of my participation in this seminar.

Participant Signature: ____________________________________ Date: _____________