ASU Western Fall Intensive 2019
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Personal Information
First Name *
Last Name *
Date of Birth *
Street Address *
City *
State *
Zip Code *
Phone Number (Home or Cell) *
Email Address *
Do you have any allergies, physical limitations, medications or medical conditions of which the dojo should be aware with regard to your safety while training or the safety of others? If these limitations may affect your training or the training of others, you are responsible for making the class instructor aware of them. *
If yes, please explain.
Emergency Contact (Name) *
Emergency Contact Phone Number *
Seminar Information
Days Planning to Attend *
(If not attending Full Camp, please check all of the days you are planning to attend)
T-shirt Size? (This question is only for people attending 4 days or Full Camp)
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Are you planning to stay at the dojo overnight? *
Are you planning on attending the Saturday dinner party? *
Are you planning on attending the "Town Hall & Lunch" on Sunday? *
Are you planning on attending the Potluck Party Sunday evening? *
Name of the dojo you are currently training at? *
Aikido Rank? *
Read & agreed to the Blood & Body Fluid Borne Pathogen Policy found at *
Read & agreed to the Consent & Assumption of Risk Statement found at *
By clicking "Submit" you are agreeing to both the Blood & Body Fluid Borne Pathogen Policy & the Consent and Assumption of Risk Statement
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