SOUTHLAND AIKIDO

670 MONTEREY PASS ROAD #210, MONTEREY PARK, CA 91754 (626) 826-1991

HARVEY KONIGSBERG 7° Dan Shihan Chief Instructor of Woodstock Aikido USAF Technical Committee Member March 25-27, 2016

Southland Aikido Dojo is honored to host an Aikido seminar with Harvey Konigsberg Sensei. Nationally and internationally renowned for his strong yet subtle style, Konigsberg Sensei teaches Aikido seminars around the world. In addition to being the chief instructor of Woodstock Aikido, he maintains a weekly teaching schedule at New York Aikikai in Manhattan. Konigsberg Sensei is a long time student of Yoshimitsu Yamada Shihan, a direct disciple of Aikido founder Morihei Ueshiba. Students of all ranks, from other dojos or other affiliations are welcome to attend. Seminar Schedule Friday, 25th: 7:00-8:30 pm Saturday, 26th: 1:00-4:30 pm; Reception at 5:00 pm Sunday, 27th: 9:00 am-12:30 pm

Seminar Fee (Cash or Check) All weekend: $125 Friday & Saturday Only: $80 Saturday & Sunday Only: $100 Friday Only: $30; Saturday Only: $65; Sunday Only: $55

Visit www.southlandaikido.org for updates and details. Contact us at dojo@southlandaikido.org for any questions about the seminar or local accomodations.

SOUTHLAND AIKIDO DOJO, 670 MONTEREY PASS ROAD #210, MONTEREY PARK, CA 91754 (626) 826-1991

Southland Aikido Seminar Registration Form

Harvey Konigsberg Sensei Seminar | March 25-27, 2016 Name: .................................................................................................................... Today’s Date: ........................................... Address: ................................................................................................................................................................................... .................................................................................................................................................................................................. Email: .................................................................................................... Phone: ...................................................................... Dojo: ..................................................................................................... Rank: .......................................................................

Seminar Fee (Choose Option)

¨ $125 Full Seminar ¨ $80 Friday & Saturday Only ¨ $100 Saturday or Sunday Only ¨ $30 Friday Only ¨ $65 Saturday Only ¨ $55 Sunday Only

Total payment: ....................................................................................... Payment method: ¨ Check ¨ Cash Make check payable to Southland Aikido. All cash payments will only be accepted at the door.

Emergency Information Emergency Contact Name ........................................................................................................................................................ Relationship to participant: ......................................................... Contact Phone Number: ...................................................

Release, Waiver of Liability & Indemnification Agreement This agreement and waiver is between Southland Aikido, hereinafter called the “Southland Aikido,” and the undersigned participant. By signing this agreement, you acknowledge that the provisions of this agreement will bind you and the terms and provisions of any Southland Aikido rules incorporated herein by reference. I, _________________________________________, the undersigned, acknowledge that I am applying for instruction in a martial art seminar involving strenuous exercise and personal body contact. I understand that because of this, there is always an inherent risk of injury that cannot be eliminated. Furthermore, I understand that while on the premises of Southland Aikido or while using its facilities or equipment, whether at Southland Aikido or at any other location for the purpose of practice or of demonstration, said premises, facilities, and equipment shall be occupied and used at the sole risk and responsibility of the undersigned, and the undersigned hereby releases Southland Aikido from any and all claims for personal injury, damage, or loss as a result of participating in the seminar. The undersigned further agrees to assure and hold harmless Southland Aikido and its instructors, teachers, directors and members from or against any and all claims made or instituted against it or them arising out of the activities of the undersigned while upon the premises of Southland Aikido or while using any of its facilities or equipment, whether at Southland Aikido or at any other location for the purpose of practice or demonstration, including injury or loss to the undersigned however caused, and injury or loss caused by the undersigned to any other person. I understand that Southland Aikido documents activities and events involving classes and instruction. I give Southland Aikido permission to use any documentation, such as videotaping, photography, or film, in which my image is taken in whatever way Southland Aikido wishes. I understand that Southland Aikido is the sole owner of this documentation. I certify by my signature that I have read and understand this agreement in its entirety and all my questions regarding it have been fully answered. Print & Sign: .................................................................................................................................... Date: ............................. (If participant is under 18, parent or guardian must sign for the underage participant.)